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i <br /> i <br /> 2/25/02 Water/Wastewater-ISTS4.31 <br /> Co.rnpliance.Tnspection t=orn' for Existing <br /> Individual Sewage Treatment Systems Minnesota Pollution <br /> Control Agency <br /> Completion of this form fulfills the trilni/naljrequirements of Minn,stat:§ 115.55 <br /> to local ordinances for (2007)and Minnesota R. ch. 70140(,1999). Please refer <br /> tither re uirements.or infomtation es .eciall f r:com liance requirements-for bedroom addliions. <br /> General...j <br /> Date of Inspection: _l I-13 -D�) I Reason foe inspection: <br /> PropertyOwner(s) S3 or( �Lpt� ���,�, �� , - Telephone (gez) 40S <br /> Person requesting-inspectton <br /> Telephone( ) <br /> Site Address City Cc9Zip Code <br /> Fire No./ Parcel No. County.' Township <br /> Legal Description <br /> Local Regulatory Authority 6.1 07 E— q•¢&q 11 p <br /> Date system constructed' r) —7L 1-06 ,iystern in Shoreland Area: yes no System in Wellhead <br /> Protection Area: yes 10 System serving a MEM licensed facility: yes(3n) Local Permit# (if any) <br /> Systems built prior.to April 1, 19-96 and not located in Systems'located in Shoreland{or Wellhdad.Protection <br /> Shoreland or Wellhead Protection-hrea 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 thread to public healthor Is the system an imminent threat to public health <br /> safely? (ayes answer Is an I7PH5 systeem)• . or safety? (a'yes answer Is an I7PHS system) <br /> -Discharge of sewage to the.ground surface? YES NO -Discharge of sewage to the ground surface? YES ,jj) <br /> -Discharge of sewage to dralritile or surface waters? YES NO -Discharge of sewage to draintile or surface waters?YES N <br /> -Sewage backup into dwelling? -YES NO -Sewage-backup Into dwelling? -YES <br /> NW <br /> -Situation with the potential to immedlately and -Situation with the potential to immedlately and <br /> adversely Impact or threaten public health or adversely impact or thteatep public health or <br /> safety? YES NO• safety? . <br /> YES CO) <br /> Is the system failing a,ypesanswel f$.a fa//ingsystem) Is the systdnn failing? (a yes•answer/sa fa//ingsystem) <br /> Less thah i V1tU feefi of vertical.separati®n between• -Less than"r REE feet of•vertical separation•between <br /> system-bottom and saturated soil or: 'YES ­NOsystem bottom Arid satuf.ated soil or bedrock? YES O <br /> -A seepage pit,cesspool,drywell,or•leaching pit? YES.'NO -A seepage pit,cesspool,drywell,or leaching pit? YES u:J <br /> Is•the system non-compliant? <br /> Is*M6 system non-compliant? <br /> Js the system regulated-under a monitoring plan or - Is the' s ste <br /> operating permit? if no . o to a e 2 Y nt'regulated under a .monitoring plan or <br /> p g p ( .9 P 9 ) YES NO operating permitT(if no,go to page-2) YES NO <br /> If yes, If yes, <br /> - Has the required monitoring taken pace? YES• NO -Has the reclulred monitoring taken plane? • YES NO <br /> ,(If no, the system l$non.-complyfng) I (if no,'the•system is non-cdm 1 !n <br /> - Does-the monitoring indicate that the system mef3ts Does:tFie mbnit6dng indicate'thafthe system meets <br /> perfoYmah'ce expectations? p6ffbrmarfce..expectations? YES NO <br /> (If no, :ft►e;sysfem is•non-cbm l in , , i ...•. .: _ .. ...: <br /> pY g) (if no, the system-7s non-complying) <br /> Page 1 of-2. . <br /> wq-wwi5ts4.31 <br />