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FROM : Rvc PHONE N0. : 4422091 Apr. 07 2004 01:44PM P1 "kt r 2/25/02 Water/Wastewater-I5T54.31 Compliance Inspection Form for Existing Individual Sewage Treatment Systems Minnesota Pollution CQ91 Agency Completion of this form fulfills the minimal requirements of Minn. Stat.§ 115.55(2001)and Minnesq ( se refer to local ordinances for other re•uirements or information. es aeciall for corn•lance re.uirements For bedroom additions. General- ,4 k .a .r. Date of Inspection: /7-A0/Reason for inspection: -.v Property Owner(s) 7 #' C//i(„7",.13 Telephones/2) a 77-7/el Person requesting inspection ,k1Mt Telephone ( ) Site Address.Z7 ' 1,4.4 i-1G oma?e dig ) / City O ,�i ' �O Zip Code � �''� � Fire No./ Parcel No. County /j/4i)et) Township Legal Description Local Regulatory Authority Ci I1 e,.✓ a Date system constructed System in Shoreland Area: ye- no System in Wellhead Protection Area: y: 411, System serving a MDH licensed facility: a no ocal Permit # (if any) Systems built prior to April 1, 1996 and not located in Systems located in Shoreland or Wellhead Protection Shoreland or Wellhead Protection Area or Serving a Food, Areas or Serving a Food, Beverage or Lodging Beverage or Lodging Establishment Establishment, or systems Built after March 31 1996 Is the system an imminent threat to Public health or Is the syaem an imminent threat,t2.geligcipalth safety? (a yes answer is an ITPHS system) or safety? (a yes answer is an IIPHS$ ' -Discharge of sewage to the ground surface? YES 40 - Discharge of sewage to the ground surfacW7, YES NO -Discharge of sewage to draintile or surface waters? YES 10 - Discharge of sewage to draintile or surface waters?YES NO -Sewage backup into dwelling? YE "-i O -Sewage backup into dwelling? YES NO -Situation with the potential to immediately and -Situation with the potential to immediately and adversely impact or threaten public health or adversely impact or threaten public health or safety? YES ' 0 safety? YES NO Is the system failing? (a yes answer is a failing system) Is the system failing? (a yes answer is a failing system) -Less than TWO feet of vertical separation between Aar -Less than THREE feet of vertical separation between system bottom and saturated soil or bedrock? 0 system bottom and saturated soil or bedrock? YES NO :OP -A seepage pit,cesspool, drywell, or leaching pit? 0 -A seepage pit, cesspool, drywell, or leaching pit? YES NO Is the system non-compliant? Is the system non-compliant? - Is the system regulated under a monitoring plan or - Is the system regulated under a monitoring plan or operating permit? (if no, go to page 2) YE NO operating permit? (if no, go to page 2) YES NO If yes, If yes, - Has the required monitoring taken place? Y,ES0 - Has the required monitoring taken placg? YES NO (If no, the system is non-complying) (If no, the system is non-comp4,q , -Does the monitoring indicate that the system meets , - Does the monitoring indicate that'th, tem meets performance expectations? Y 0 performance expectations'? ` ' , YES NO (If no, the system is non-complying) (If no, the system is non-complying) Page 1. of 2 wq-wwists4.31