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W ateri Wastewater-ISTS4.31
<br /> Compliance lnsp'.;,-". ! Form for Existing '
<br /> Individual Sewage Treatment aystems P" = VED
<br /> This form reflects the requirements of the 1996 version of MNRules Chapter 7080 F; 2001.
<br /> Minnesota Pollution Control Agency
<br /> Notj:Local inspection standards maybe more or less restrictive than the state requirements. These differences must be rhadc eveilablo b5ohi%ocal
<br /> Unit of Government.
<br /> Date
<br /> Yroper.y 011 ueI ts —.— _ -- _ _ Telephone((41� -
<br /> fir VI1CC� --� Z •__-• 1 tilcphone(741—dM749 ,Z
<br /> i:eu5utt for is t• :t.'1 - _ _
<br /> Site Address 3 City
<br /> Zip Code_ — _ _ Unii of CovertttneiU Regulating this property' aaAmf�
<br /> Fire No. - --- -- I'dreel No. � 'Township Na.nt:9U116-
<br /> Tc, kallge section Quarter_-._
<br /> 1 fieck approi,i!.,i.,se:vcr system cumponcnt and indicate location on site sketch).
<br /> i:cut: W. : sur t 1111111-01 nt"Astor:: Other(briefly [Describe): r-tow
<br /> Se;xic tank _Rock trench —Alternative system
<br /> __:►erotic 2..:;: ;r.v.alcss:;i;e:re<ca _Experimental system�— —_ Yes ISO
<br /> t—ne;, Warrantied system —__ __. If yes,
<br /> — I iuldlnL 1.:,1 I'l:o rp, Date:
<br /> t.ith�r h1O•nc ?t!ier
<br /> --- _-r\[-trade ----- --- --_—.
<br /> System Classification
<br /> System Guilt Prior to April 1, 1996 and riot Located in Any System: iok; aed in Shoreland or Wellhead
<br /> Shoreland c.r Wellhead Protection Area or Serving�al- Protection Area'or,Servinb a Food';$everage or Lodging
<br /> Food, Beverage or Lodging Establishment Establishment, plus all systems Built after
<br /> April 1. 1996
<br /> Is the systert:ul imminent public health threat IYH Upgrade Is ne system an IPHT? Unerade
<br /> I.U;schaig. f sewage to the around surface? YES Q0 10 mo 1.Discharge of sewage to the ground surface? YES NO 10 mo
<br /> 2.Dischar,'.;of sc,%age to draintile 2.Discharge of sewage to draintile or
<br /> Or surt:rcc YES t 10,vo surface waters? YES NO 10 mo
<br /> 3. Sewage backot—rito YES NO 10 ino 3.Sewage Lxkup into dwelling? YES NO 10 mo
<br /> 4. S,tuan::!,,vith!1-pt&.t.':I'o iilhi!-:O:at'ly ar 4.Situation with the potential immediately and
<br /> adversely in-,;Mc; ur a., ,ir.:;r,'^ h:ala• x adversely irlp':ct or threaten public health or
<br /> safety! r_'S C 10 nio I safety? YES NO 10 mo
<br /> Is the s�'�tcuf iatlill',' is the system All_iui'
<br /> 5. Less than TWO Bert of verctc:a separation between 5. Less than THREE feet of vertical separation between
<br /> system bottom and st:tuiated soil or bedrock? NO LGU** system bottom and saturated soil or 6,:drock? YES NO LGU**
<br /> G. A sec aut ii[,c:s out drtiwell,or leaching it'? ESy NO LGU** G.A seepage,pit, ressi-lol,drywell,or leaching pit?YES NO LGU**
<br /> •• LGU_Luc:,l Unit of Government urdinance must sperify the time period within which the system m:: :t:c upgraded.
<br /> Wrr�rrnrr.ri�....ee.,.*ts.sPw. +�errara atrot�;.•�••ao u.'etr,
<br /> STATUS OF]
<br /> ti2laid Ell file C��. ,,,L'd^:'4 l-"lh.r l{ :.bl Yl•all•: ,': -:1 MIS isi nO� 0 in.compliance;functioning))(failing 13 an imminent threat
<br /> therefore,this,l,.cuu,c,l! ai-1 f;001._,. It,!Of Cu n;'Iiarc.e�:'Mice of Noncomptirtnco.
<br /> used to make; the.!eterntin tfoils f lr'the compliance i[ls}rcuiul? .i, 1�11r C /'7
<br /> `7�u.;'iyrL N/�'%. d.i/CZG �_�1_1C1i�i
<br /> -'dam -- -- - — --
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