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05/09/2012 14:29 9528733112 PAGE 03/05 Parcel number: _ System status: Compliant ❑ Noncompliant (as determined y t is form) Hydraulic Performance and Other Compliance Compliance Issue #1 f 4 Date of observation: Reason for observation: --. This form expires upon ne Inspection or in three years,whichever occurs first: _Compliance questions/criteria: (Required) Verification Method: (Optional) (Check the appropriate box) (Check the appropriate box) Does the system discharge sewage to the 0 Yes No Searched for surface outlet ground surface? ® Performed hydraulic test Does the system discharge sewage to drain ❑ Yes No tile or surface waters? K Searched for seeping in yard Does the system cause sewage backup 0 Yes No ❑ Checked for backup in home into dwelling or establishment? 0 Excessive ponding in soil system/D-boxes Do other situations exist that have the . ❑ Yes No ❑ Homeowner testimony potential to immediately and adversely pxamined for surging in tank impact or threaten public health or safety ( lectrical, unsafe covers,etc.)? _ -- ❑ "Black soil"above soil dispersal system Any"yes"answer indicates that the system is an imminent threat to public health and safety. ❑ System requires"emergency"pumping _ 0 Performed dye test Does the system pose a threat to ground ❑ Yes ;Z1 No ❑ Other; water for any conditions deemed non- protective as determined by the inspector? -- "Yes"indicates that the system Is failing to protect - . ___ __._.__.. ground water. If"yes", describe the condition noted: No standard protocol exists. This list is not exhaustive, in sequential order, nor does it indicate which combinations are necessary to make this determination. Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's (MPCA) Compliance Inspection Form for Existing Subsurface Sewage Treatment Systems. Observations, interpretations, and conclusions must be completed by an inspector. Completed form must be submitted to the local unit of government within 15 days. Property owner name(s): .,i \ --- Property address: V765- ,5' idA. L.ti it 119 ,1;17: . Oriii0 — Property ow is address (If different): County: _ _ Phone: --_ I hereby certify that I personally made the observations, interpretations, and conclusions reported on this form and that they are correct. Name: --"&e.\•\ \Vn Certification number: Tu,59 . .., Business license name and number: S 61/4, ► Ce- \Irec S a_.. - or Name of local unit of,?o -rnmen IQ —.-- / , Signature: d�f _ / /i.... Date: % L wo-wwists4.31 Compliance Inspection Form for Existing SSTS