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FROM :,I,JALDENLIOOD FAX NO. :9529748446 Jul. 30 2007 10:35AM P3 <br /> ..cr <br /> • • 11/2001 Water/Wastewater-ISTS4.31 <br /> Compliance Inspection Form for Existing <br /> 4104 Individual Sewage Treatment Systems Minnesota Pollution <br /> Control Agency <br /> Completion of this form fulfills the minimal requirements of Minn, Stat. § 115.55(1999)and Minnesota R, ch. 7080(1999), Please <br /> refer to local ordinances for other re•uirements or other re•ulred Information. <br /> General: <br /> Date of Inspection: ?ftI' Reason for inspection; <br /> Property Owner(s) ^ (� (� h Telephone ( ) <br /> Person requesting Inspection �JQQ Airt&A..cc .(06-CIOLA/N 0o4.,o0 1-7M)Teiephone (96?--. 11V-IS q 7.-- <br /> Site <br /> Z <br /> Site Address 40 & � i.ff i� 6 City O C) Zip Code <br /> Fire No./ Parcel No. Township Name <br /> Legal Description (to LJJ E.p C4_, LA 0 E • 02006 1110, <br /> Regulatory Authority Gay O f D(�! _- - <br /> it: <br /> r.Q.,(4,14}(-................ ...2 .../ <br /> System CI@ <br /> ssificatiort .<ye-,,t1,&) „,„-,,-„iwv,, <br /> Systems built prior to April 1, 1996 and not located in Systems located.in Shoreland or Wellhead Protection <br /> Shoreland or Wellhead Protection Area or Serving a Food, Areas or Serving a Food, Beverage or Lodging <br /> Beverage or Lodging Establishment Establishment, or systems Built after <br /> March 31996 <br /> = • 7 - it =.i 1' , I II , _• •ublic - - . or Is the system an imminent threat to public health <br /> safety? (a yes answer is an ITPHS system) gr safety? (a yes answer Is an 1TPHS system) <br /> -Discharge of sewage to the ground surface? ZS NO - Discharge of sewage to the ground surface? YES Rt@ <br /> - Discharge of sewage to draintile or surface waters? ES NO - Discharge of sewage to draintile or surface waters? YES darf <br /> -Sewage backup Into dwelling? YES NO - Sewage backup into dwelling? YES IC <br /> -:Situation with the potentia) to Immediately and - Situation with the potential to immediately and <br /> adversely impact or threaten public health or adversely impact or threaten public health or <br /> safety? YES NO safety? YES(NO <br /> Is the system failing? (a yes answer is a falling system) Is the system failing? (a yes answer is a falling system <br /> -Less than TWO feet of vertical separation between - Less than THREE feet of vertical separation between <br /> . system bottom and saturated soil or bedrock? YES NO system bottom and saturated soil or bedrock? YES NO- <br /> -A seepage pit, cesspool, drywell, or leaching pit? YES NO -A seepage pit, cesspool, drywell, or leaching pit? YES 0, <br /> Is the sntem non-comliant? Is the system non-comp ant? , <br /> - Is the system regulated under a monitoring plan,or - Is the system regulated under a monitoring plan or <br /> operating permit? (if no, go to page 2) YES NO operating permit? (if no, go to page 2) YES NO <br /> If yes, • , If yes, <br /> - Has the'required monitoring taken place? YES NO - Has the required monitoring taken place? YES NO <br /> (Itno, the system Is non-complying) (If no, the system is non-complying) <br /> -The monitoring Indicate that the system meets -The monitoring indicate that the system meets <br /> performance expectations? . YES NO performance expectations? YES NO <br /> (If no, the system is non-complying) (If no, the system Is non-complying) <br /> • <br /> Page 1 of 2 wq-wwists4.31 <br />