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9j164. (6 0 V) Compliance Inspection Form for Existing _ <br /> 41,4'..w ir. Individual Sewage Treatment Systems `"� <br /> This form reflects the requirements of the 1996 version of MN Rules Chapter 7080 �`'�''')� 1 20011 <br /> Minnesota Pollution Control Agency k;l d ,b' ` , (LA-1'i Ago <br /> Note:Local inspection standards may be more or less restrictive than the state requirements. These differences must be made available by the Local <br /> Unit of Government. <br /> Date of Inspection: c'.T- k: -Zcc c-, <br /> Property Owner(s) /2.I 4r / 4 Fes. Telephone( ) 4),•71-_:;;;;T.,--'-v" -d/ <br /> Person requesting inspection(if different than owner) Telephone( ) <br /> Reason for inspection: '""44,.. i'-' -7; ;f <br /> Site Address 1` _ <br /> l/ > <br /> (`i�r�:GC ,,J"'��" i��L// %C' � IA-) City -. 4''- F -'' l:a <br /> Zip Code Unit of Government Regulating this property (4 y 4 <br /> Fire No. Parcel No. Township Name <br /> Township Range Section Quarter <br /> (Check appropriate sewer system component and indicate location on site sketch). <br /> Tank(s): Soil Treatment System: Other(briefly describe): Flow Meter <br /> I Septic tank _Rock trench —Alternative system <br /> Aerobic tank _Gravelless pipe trench Experimental system Yes No - <br /> / Pump tank Chamber trench _Warrantied system If yes, <br /> _Holding tank _Seepage bed Exp.Date: <br /> —Other V' Mound Other <br /> _At-grade <br /> System Classification <br /> System Built Prior to April 1, 1996 and not Located in Any System located in Shoreland or Wellhead <br /> Shoreland or Wellhead Protection Area or Serving a Protection Area or Serving a Food, Beverage or <br /> Food, Beverage or Lodging Establishment Lodging Establishment, plus all systems Built after <br /> April 1, 1996 <br /> Is the system an imminent public health threat(IPHT)?Upgrade Is the system an IPHT? Upgrade <br /> 1.Discharge of sewage to the ground surface? YES CN9 10 mo 1.Discharge of sewage to the ground surface? YES NO 10 mo <br /> 2.Discharge of sewage to draintile 2.Discharge of sewage to draintile or <br /> or surface waters? YES 110 10 mo surface waters? YES NO 10 mo <br /> 3.Sewage backup into dwelling? YES (NO 10 mo 3. Sewage backup into dwelling? YES NO 10 mo <br /> 4. Situation with the potential to immediately and 4.Situation with the potential immediately and <br /> adversely impact or threaten public health oradversely impact or threaten public health or <br /> safety? YES (-9.- 10 mo safety? YES NO 10 mo <br /> Is the system failing? Is the system failing? <br /> 5.Less than TWO feet of vertical separation between 5.Less than THREE feet of vertical separation between <br /> system bottom and saturated soil or bedrock? YES 0 LGU** system bottom and saturated soil or bedrock? YES NO LGU** <br /> 6.A seepage pit,cesspool,drywell,or leaching pit? YES(NQ) LGU** 6.A seepage pit, cesspool,drywell,or leaching pit?YES NO LGU** <br /> **LGU=Local Unit of Government ordinance must specify the time period within which the system must be upgraded. <br /> STATUS OF THE SYSTEM <br /> Based on the compliance criteria above t e ystem status is (check one)L]in compliance(functioning)0 failing 0 an imminent threat <br /> therefore,this document is a(check one) Certificate of Compliance 0 Notice of Noncompliance. <br /> Page 1 of 2 <br />