Compliance Inspection Form for Individual Sewage

Home Browse Search

FROM 4 RYS PHONE NO. : 4422091 Mar. 13 2005 08:43PM P1 2/25/02 Water/Wastewater-ISTS4.31 Compliance Inspection Form for Existing -mss Individual Sewage Treatment Systems Minnesota nnesr ti lllution Agency Completion of this form fuflls the minimal requirements of Minn, Stat. § 115.55(2001)and Minnesota R. ch. 7080(1999). Please refer to local ordinances for other requirements or information,especially for compliance requirements for bedroom additions. General: Date of Inspection: Reason for inspection: �0AN /11F/2i ce Property Owners) de;7v 'Telephone Person requesting inspectionTelephone( ) Site Address -3L f-9— city Zip Code^-clzi Fire No./ Parcel No. County Township Legal Description / / Local Regulatory Authority�l ec/ T Date system constructed `�" q8 System in Shoreland Area: yes�no System in Wellhead Protection Area: yes-6 System serving a MDH licensed facility: ye no Local Permit* (if any) Systems built prior to April 1, 1996 and not located in Systems located in Shoreland or Wellhead Protection Shoreland or Wellhead Protection Area or Serving a Food, Areas or Serving a Food, Beverage or Lodging Beverage or Lodging Establishment Establishment, or systems Built after March 31 1996 Is the system an imminent threat to public health or Ys the system an imminent threat to Public health safjW. (ayes answer is an 17PHS system) or safety? (a yes answer is an 17PHS system) Discharge of sewage to the ground surface? YES NO -Discharge of sewage to the ground surface? YES 0 -Discharge of sewage to draintile or surface waters? YES NO -Discharge of sewage to draintile or surface wagers?YES NO -Sewage backup into dwelling? YES NO -Sewage backup into dwelling? YES -Situation with the potential to immediately and -Situation with the potential to immediately and adversely impact or threaten public health or adversely impact or threaten public health or safety/? YES NO safety? YES NO Is the system failing? (a yes answer is a failing system) Is the system failing? (a yes answer is a failing system) -Less than TWO feet of vertical separation between -Less than THREE feet of vertical separation between system bottom and saturated soil or bedrock? YES NO system bottom and saturated soil or bedrock? YES 0 -A seepage pit,cesspool,drywell,or leaching pit? YES NO -A seepage pit, cesspool,drywell, or leaching pit? YES Is the system non-compliant? Is the system non-compliant? - Is the system regulated under a monitoring plan or - Is the system regulated under a monitoring plan or operating permit? (if no,go to page 2) YES NO operating permit? (if no,go to page 2) If yes, If yes, -Has the required monitoring taken place? YES NO -Has the required monitoring taken place? N (lf no, the system is non-complying) (If no,the system is non-complying) -Does the monitoring indicate that the system meets - Does the monitoring indicate that the system meets performance expectations? YES NO performance expectations? (If.no, the system is non-complying) (If no, the system is non-complying) Paqe 1 of 2 wa-vvwists4.31