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Parcel number: System status: ('i Compliant LI Noncompliant <br /> (as determined by this form) <br /> • <br /> • <br /> Hydraulic Performance and Other Compliance — Compliance Inspection Form for Existing SSTS <br /> Compliance Issue #1 of 4 <br /> Date of observation: ) ) - 'l. ^ pq . Reason for observation: ' A.11‘..‘PY1.1 <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) _ (Check the appropriate box) <br /> Does the system discharge sewage to the ❑ Yes I No <br /> CI Searched for surface outlet <br /> ground surface? <br /> ❑ Performed hydraulic test <br /> Does the system discharge sewage to drain I ❑ Yes ❑ No • <br /> tile or surface waters? i.tJ Searched for seeping in yardl l <br /> Does the system cause sewage backup iCIYes No 111Checked for backup in home <br /> • <br /> into dwelling or establishment? <br /> ® Excessive ponding in soil system/D-boxes 140 <br /> Do other situations exist that have the ❑ Yes M No <br /> potential to immediately and adversely [11 Homeowner testimony <br /> impact or threaten public health or safety ❑ Examined for surging in tank <br /> (electrical,unsafe covers, etc.)? <br /> .® "Black soil"above soil dispersal system 11.0 <br /> Any"yes"answer indicates that the system is an imminent <br /> threat to public health and safety. ❑ System requires"emergency"pumping <br /> ❑ Performed dye test <br /> Does the system pose a threat to ground ❑ Yes Iki No <br /> water for any conditions deemed non- [1] 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 /> in sequential order, nor does it indicate which <br /> combinations are necessary to make this determination. <br /> Certification <br /> • <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): ),fit Lc� V A)a4VA1 <br /> Property address: 'Zg c,-)0 5d 'SLR A z ) iia �!R <br /> Property owner's address(if different): <br /> County: \ �� '1 Property owner phone: -- �7 <br /> 1 hereby certify that I personally made the observations, interpretations, and conclusions reported on this form and that they are <br /> correct. - <br /> Name: G-<....\/ a (4). 5 C,'1 7-M e. Certification number: (o ot') <br /> Business license name and number: 5-'ri7`(' t1)J )'C , ��I C9 i)lrn -3 5 or <br /> Name of local nit of government: <br /> Signature: , --^^---- Date: <br /> • <br /> www.pca.state.mri.us • 651-296-6300 • 800-657,38-64-x.,• TTY 651-282-5332 or 800-657-3864 • Available in alternative formats <br /> wq-wwists4-31 • 4/10/09 Page 2 of 8 <br />