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Parcel number: _ System status: Compliant ❑ Noncompliant <br /> (as determine by is form) <br /> Hydraulic Performance and Other Compliance <br /> Compliance Issue #1 of 4 <br /> Date of observation: `© �� <br /> 1 3 1\ - Reason for observation: <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 No yr Searched for surface outlet <br /> ground surface? <br /> ® Performed hydraulic test <br /> Does the system discharge sewage to drain ❑ Yes ii No <br /> tile or surface waters? Searched for seeping in yard <br /> Does the system cause sewage backup ❑Yes 1A No 0 Checked for backup in home <br /> into dwelling or establishment? <br /> ❑ Excessive ponding in soil system/D-boxes <br /> Do other situations exist that have the . ❑Yes XNo 0 Homeowner testimony <br /> potential to immediately and adversely <br /> impact or threaten public health or safety ,xamined for surging in rank <br /> (electrical, unsafe covers etc. ? <br /> 0 "Black soil"above soil dispersal system <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 sNo ❑ Other: <br /> water for any conditions deemed non- <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 /> 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. Completedorm must be submitted to the local unit of government within 15 days. <br /> cp. <br /> Property owner name(s): _8164.421-di Lr E <br /> yieryL. i ...__ <br /> Property address: /220 "' AY/ t_ R - 0),,e) <br /> _..... <br /> Property owner's (if different): <br /> County: 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 /> Name: _— N. _._ _ Certification number: 1�p 1 <br /> Business license name and number: _ - Co .� �hC � 1 _____. ..-,, or <br /> Name of local unit of o rnm=- : / / „ <br /> Signature: �-://«i// Date: !t I>I — .....—_... ... <br /> wq•wwists4-31 Compliance Inspection Form for Existing 5ST5 <br /> 411108 • <br /> 913/ la 39dd ZTTEEL8ZS6 9T :ZT TT9Z/b0/0T <br />