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03/09/2010 01:28 7634975011 SPTESTINGINC PAGE 05/13 Parcel number: • • • . _ •• _ System status: 0 Compliant Nit (as determined by this form) Noncompliant ' Hydraulic Performance and Other Compliance - Compliance Inspection Form for ExistingS. Compliance Issue #1 of 4 STS Date of observation; • o) Q Reason for observation: / This form expires upon next inspection or in three years,whichever occflrs first: Compliance questions/criteria: (Required) (Chec/t the ap�aropriate bbxJ Verification Method`: (Optional) Does the system discharge sewage to the0 Searched for surface outletoutlet(Check the appropriate box) _ground surface? 0 Yes No Does(lie system discharge sewage to drain I 0 Yes ❑ No 0 Performed hydraulic lest, Tile or surface waters? — ell Searched for seeping in yard RZI Does the system cause sewage backup � 0 Yes tL'I No• 0 Checked for backup Into dwelling or establishment? in home • I- — SLI Excessive ponding In soil system/D-boxes 110 Do other situations exist that have the : 0 Yes C'i; No potential to immediately and adversely ❑ I-lornoowner testimony impact or threaten public health or safely (electrical unsafe covers, etc,)? n Examined for surging in tank Anya " Black lollabove soil dispersal system hVO "yes"answer indicgtes that the system Is an imminent threat to public health and safety. f] System requires"emergency"pumping •Does the system pose a threat to ground ❑ l'eliormetl'dye test water for any conditions deemed non- • Yes is�J No Other �^ _ 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 llst is not exhaustive, in sequential order, nor does It Indicate which combinations are necessary to make this determination. • Certification This form Is to he completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPGA) Compliance Inspection Form for Existing Subsurface Sewage Treatment Systems.'Observations,Interpretations, and conclusions must be completed by an Inspector. Completed Form must be submitled'to the local unit of government within 15 days. Property owner name(s): -M 4OWI erg. ' Property address: 40 U1. iq� L► 14,9 0%2J-36 Properly owner's address(If different): _ County: 1u °r'+�t Property - owner phone: Ie 1�L�,t,fr • I hereby certify that i personally made the observations, interpretations, and conclusions reported on this form and that they are correct. Name: ,,.\/_21__5-6, 51st•4011.• j, Certification number: Business license name and.number: -57 4.0,1./'�11�1�� L ty t 9 Name of loca.I knit of government: Signature: � -- j.w (r, Date: 3- - • • wwva.pca,state,mri,lis' •• 651.296-6300 • y 800-657.3.961-- TTY 651-28275332 or 800.657-3864 • Available in alternative formats wq-wwFsf54-31 - 4110/09 •`�