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Parcel number: <br /> System status: KCompliant ❑ Noncompliant <br /> (as determined by this form) <br /> Hydraulic Performance and Other Compliance <br /> Compliance Issue #1 of 4 <br /> Date of observation: o Reason for observation: S <br /> This form expires upon next inspection or in three years,whichever occurs first: <br /> Compliance questions/criteria: (Required) <br /> Check the a..ro.riate box Verification Method*: (Optional) <br /> (Check the appropriate box) <br /> ❑ YesN <br /> Does the system discharge sewage to the <br /> .round surface? o ( Searched for surface outlet • <br /> Does the system discharge sewage to drain ❑Yes jNo Ci Performed hydraulic test <br /> tile or surface waters? kSearched for seeping in yard <br /> Does the system cause sewage backup ❑ Yes V, No <br /> into dwellinq or establishment? r ❑ Checked for backup in home <br /> Do other situations exist that have the CI Excessive ponding in soil system/D-boxes <br /> potential to immediately and adversely ❑YesNo <br /> ❑ Homeowner testimony <br /> impact or threaten public health or safety <br /> electrical, unsafe covers, etc. ? CI Examined for surging in tank <br /> Any"yes"answer indicates that the system is an imminent CI “Black soil"above soil dispersal system <br /> threat to public health and safety. <br /> ❑ System requires"emergency"pumping <br /> El Performed dye test <br /> Does the system pose a threat to ground <br /> water for any conditions deemed non- CI Yes No <br /> [11 Other: <br /> •rotective as determined b the ins•ector? <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 /> 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): <br /> Property address: ___J ®Q ‘.)d 44, e," <br /> Property owner's address(if different): -- <br /> — <br /> County: ____6/5-1 ,1(.." <br /> 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 /> • <br /> Name: j®/dt✓i e h,+�z--A---- �,� <br /> Certification number: <br /> Business license name and number: ht C 71k v <br /> Name of local un' go rnment: - ®be®es <br /> Signature: IP" /6 „P <br /> ... f.4 <br /> i i. . Date: o <br /> vq-wwists4-31 <br /> I/1/08 Compliance Inspection Form for Existing SSTS <br />