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05/09/2011 10:05 9528733112 PAGE 02/04 <br /> Parcel number: <br /> —'-- -- System statusAby <br /> Compliant ❑ Noncompliant <br /> (as determinehis/arm) <br /> Hydraulic Performance and Other Compliance <br /> Compliance Issue #1 of 4 <br /> Data of observation: ��A_ Reason for observation: <br /> This form expires upon next Inspection or in three years,whichever occurs first; <br /> Compliance questions/criteria: (Required) <br /> Check the ro rials bvx Verification Method'": (Optional) <br /> Does the system discharge sewage to the (Check the appropriate box) <br /> round surface? ❑Yes No K.Searched for surface outlet <br /> Does the system discharge sewage to drain y❑Yes N0 ® Performed hydraulic test <br /> file or surface waters? Searched for 9in y seeping and <br /> p <br /> Does the system cause sewage backup ❑Yes No ❑ Checked for backup in home <br /> into dwelling or establishment? <br /> Do other situations exist that have the ❑Yes No ❑ Excessive ponding In soil system/D-boxes <br /> potential to immediately and adversely ❑ Homeowner testimony <br /> Impact or threaten public health or safety <br /> electrical unsafe covers etc.)? ,(Examined for surging In tank <br /> Any"yes"answer Indicates that the system Is an imminent ❑ 'Black soir above soil dispersal system <br /> threat to public health and safety. <br /> ❑ System requires"emergency'pumping <br /> Does the system pose a threat to ground ❑Yes No ❑ Performed dye test <br /> water for any conditions deemed non- ❑ Other: <br /> protective as determined b the ins ecto� -""---' ---- <br /> "Yes"indicates that the system is failing to protect <br /> ground water. if"yes'; describe the condit/on noted: _..,,_. .. .. <br /> 'No standard protocol exists. This list is not exhaustive, <br /> in sequential order, nor does it indicate which <br /> combinations are necessary to make this determination. <br /> Certification <br /> This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compliance <br /> Inspection Form for Existing Subsurface Sewage Treatment Systems. Observations, interpretations,and conclusions must be <br /> completed by an inspector.Completed form must be submitted to the local unit of government within 15 days, <br /> Property owner name(s); <br /> Property address: -- ---- ---- - .. <br /> IPA <br /> Property owner' address(if dlfferent): - -- <br /> County: /j <br /> Phone: <br /> I hereby certify that l personalty made the observations,interpretations, and conclusions reported on this form and that They are <br /> correct. <br /> Name: Certification number: <br /> Business license name and number: 1 - ^ -- •- <br /> (gs or <br /> Name of local unit of ernm ---- <br /> Signature: <br /> Date: <br /> wq-wwfsts4-3 f <br /> 411108 Compliance Inspection Form for Existing 55TS <br />