Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
10/15/2009 16: 15 9528733112 PAGE 02105 <br /> Parcel number: --- System status: <br /> Y Compliant liant <br /> ❑ Noncompliant <br /> (as determined this form) <br /> Hydraulic Performance and Other Compliance <br /> Compliance Issue #1 of 4 <br /> Date of observation: 10 ( ILl I_01 Reason for observation: 4;1`el <br /> This form expires upon next inspection or in three years,whichever occurs first: <br /> Compliance questions/criteria: (Required) Verification Method*: (Optional) <br /> (Check the appropriate box) <br /> (Check the appropriate box) <br /> Does the system discharge sewage to the El Yes (KNo <br /> ground surface Searched for surface outlet <br /> Does the system discharge sewage to drain CIYes 14 No ® Performed hydraulic test <br /> _tile or surface waters? tlif Searched for seeping in yard <br /> Does the system cause sewage backup ❑ Yes No 0 Checked for backup in home <br /> into dwellinpi or establishment? <br /> 0 Excessive ponding in soil system(D-boxes <br /> Do other situations exist that have the ❑Yes jifklo <br /> potential to immediately and adversely ❑ Homeowner testimony <br /> impact or threaten public health or safety i Examined for surging in tank <br /> (electrical,unsafe covers,etc. ? <br /> Any"yes"answer indicates that the system is an imminent 0 "Black soil"above soil dispersal system <br /> threat to public health and safety. [] System requires"emergency'pumping <br /> C] Performed dye test <br /> Does the system pose a threat to ground ❑ Yes No <br /> water for any conditions deemed non- ❑ Other: <br /> protective as determined by the inspector? <br /> "Yes"indicates that the system is failing to protect - <br /> ground water. If"yes" describe the condition noted: --- -- <br /> 'No standard protocol exists. This list is not exhaustive, <br /> I <br /> ' in sequential order, nor does it indicate which <br /> combinations are necessary to make this determination. <br /> I <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 t y an inspector. Completed form must be submitted to the local unit of government within 15 days. <br /> Property owner name(s)C: �ill it sa to 1 s�i r fl sa n <br /> Property address: Z —� W " cII d, 553S-Co <br /> a D ro fl b�� M J� SS3S-(o <br /> Property owner's address(if different): — — <br /> County: 4:10/nTi r. Phone: <br /> I hereby certify that I personally made the observations, interpretations, and conclusions reported on this form and that they are <br /> correct. <br /> Name: 1 ealorNC) Certification number: p,1(,56r .___...._ <br /> Business license name and number: CSA ye a)uNa Spx u1t-QS EriL ..- 50 or <br /> Name of local unit of goent: <br /> Signature: Date: 10.11510C1 . .. . — <br /> • <br /> • <br /> wq-wwists4-31 Compliance Inspection Form for Existing SS TS <br /> 4/1/08 <br />