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' Parcel number: 3 ) I )Scy 33/ 00 0 5 System status: ❑ Compliant gt Noncompliant (as determined by this form) Hydraulic Performance and Other Compliance - Compliance Issue #1 of 4 IL-LaiZO If Reu:>or. uuservation. C--...L ....1 /w5 Date of ubsc-rvation: -I his form expires upon next inspection or in mice yeu I s. wnichever occurs first. Compliance questions/criteria: (Required) Verification Method': (Optional) (Ctmck the appropliate box) (Check the appropriate box) Does the system discharge sewage to the ❑ Yes (3 No ® Searched for surface outlet . 1 -groune_su face? - - — 0 Performed hydraulic test Dues the system discharge sewage to drain ❑ Yes ® No ® Searched for seeping in yard tile or surface waters? -__ I-,Does pre system cause sewage backup NYes ❑ No -E. Checked for backup in home IMO dwelling or establishment? ❑ Excessive ponding in soil systemiD-boxes Do other situations exist that have the kl Yes ❑ No Homeowner testimony potential to immediately and adversely Examined for surging in tank impact or threaten public health or safety -I�lectrica-,_unsafe covers,etc)? • -____-__ ❑ "Black soil" above soil dispersarsystern Any"yes' answer indicates that the system is rnr imminent System requires"emergency" pumping rnreat to public health and safety. .___-.__-_ ❑ Performed dye test Does the system pose a threat to ground 1 `IIS Yes ❑ No ❑ Other0 Ai;4. 7µNr (S /4(LG_ tj►tel water for any conditions deemed non- i ,totec,tive as determined by the ins ector? i ECt) 1 l)l \atn'r 1. P-- � A- -- "Yes"indicates that the system is failing to protect ��v MP 1 • S N''` �` . �"C ^-_-- ground water. If"yes", describe the conditionroted: •No standard protocol exists. This list is not exhaustive, {� • __ ___ _ in sequential order, nor dpes it indicate which' - - combinations are necessary to make this determination. Certification . This forni is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's (MPCA) Compliance Inspection Form for Existing Subsurface Sewage Treatment Systems. Observations, interpretations, and conclusions must be completed by an inspector. Completed form must be submitted to the local unit of government within 15 days. Property owner name(s): k.A Oh it)D 6 i s- CiZFH i.r>i2) -Ai _ ----- z. To T&4eE) g74/4.4-.--p ,4-1A)� �l1A) (afZo„Jo)Property address: S � G �t 2_ ) fro Property owner's address (if different): 640---01C173-4- • ,_1 , _ (- County: k �C"" , Phone: V(0 fir_ --- -- Gf2 - 2-c - ti,-f 1 hereby certify that 1 personally nlrade the ()User iuc,ur,s, interpretations, and conclusions reported on this bourn unci mal :ney clre coirect. "_,,,/Z - • Name: I Cj ; c(_1-1 Certification number: /4/ 2 7 Business license name and number: � 1 t �5 so 'L.. T 57Iw9 1/ /93 --- or Nanru of localf overnme� Kc: �— nnt: C._,/ r` c' F Q/ (s1vo --- -- Signature: " L ^" l ...--- •Date: �"2 a/ ZG 0 --- — • wywwists4-31 Compliance Inspection Form for Existing SSI S d/1/UJ ,