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2/25/02 Water/Wastewater-ISTS4.31 <br /> A. <br /> Compliance Inspection Form for Existing Minnesota Pollution <br /> Individual Sewage Treatment Systems Control Agency <br /> Completion of this form fulfills the minimal requirements of Minn. Stat. § 115.55(2001)and Minnesota R. ch. 7080(1999). Please refer <br /> to local ordinances for other requirements or information,especially for com liance requirements for bedroom additions. <br /> General: I <br /> Date of inspection: '0 Reason fo Inspection: . <br /> Property Owner(s) I'al A telephone (ISA <br /> Person requesting inspection Telephone ( ) -- <br /> Site Address City jorF%io Zip Code <br /> Fire No./ Parcel No. County ✓1 i oe if`- Township <br /> Legal Desorption <br /> Local Regulatory Authority C-� <br /> Date system constructed ITi System in Shoreland Area: yes System in Wellhead <br /> Protection Area: yes(D System serving a MDH licensed facility: yesn Local Permit # (if any) <br /> Systems built prior to April 1, 1996 and not located in Systems located in Shoreland or Wellhead Protection <br /> Shoreland or Wellhead Protection Area or Serving a Food, Areas or Serving a Food, Beverage or Lodging <br /> Beverage or Lodging Establishment Establishment, or systems Built after <br /> March 31 1996 <br /> is the system an imminent threat to public health or is the system an imminent threat to public health <br /> safety? (ayes answer is an ITPHS system) sae (a yes answer is an 17PHS system) <br /> ES <br /> -Discharge of sewage to the ground surface? YES NO - Discharge of sewage to the ground surface? YE <br /> -Discharge of sewage to draintile or surface waters? YES NO -Discharge of sewage to draintile or surface waters?YES 0 <br /> -Sewage backup into dwelling? YES NO -Sewage backup into dwelling? YES <br /> -Situation with the potential to immediately and -Situation with the potential to immediately and <br /> adversely impact or threaten public health or adversely impact or threaten public health or <br /> safety? YES NO safety? YES <br /> Is the system failing? (a yes answer is a failing system) is the system failing? (a yes answer is a failing system) <br /> -Less than TWO feet of vertical separation between -Less than THREE feet of vertical separation between <br /> system bottom and saturated soil or bedrock? YES NO system bottom and saturated soil or bedrock? YES <br /> -A seepage pit,cesspool,drywell, or leaching pit? YES NO -A seepage pit,cesspool, drywell, or leaching pit? YES <br /> Is the system non-compliant? Is the system non-compliant? <br /> - Is the system regulated under a monitoring plan or - Is the system regulated under a monitoring plan or <br /> operating permit? (if no, go to page 2) <br /> YES NO operating permit? (if no,go to page 2) YES NO <br /> If yes, If yes, <br /> Has the required monitoring taken place? YES NO - Has the required monitoring taken place? YES NO <br /> (If no, the system is non-complying) (If no, the system is non-complying) <br /> - Does the monitoring indicate that the system meets - Does the monitoring indicate that the system meets <br /> performance expectations? YES NO performance expectations? YES NO <br /> (If no, the system is non-complying) (if no, the system is non-complying) <br /> Page 1 of 2 wq-wwist54.31 <br /> T -d 262E-ELB (ass) punTpamS 4sor d82 :20 BO 20 Jew <br />