Onsite sewage treatment system - Laserfiche WebLink

Home Browse Search

Parcel number: System status: ❑Compliant ®Noncompliant (as determined by this form) Hydraulic Performance and Other Compliance Compliance Issue #1 of 4 Date of observation: 9-I I -O!� Reason for obsery tion: -SOS� 41- 1�►r»S This form expires upon next inspection or in three years,which ver occurs first: Compliance questions/criteria: (Required) Check thea roriate box Verification Method'`: (Optional) (Check the appropriate box) Does the system discharge sewage to the ❑Yes ® No round surface? ❑ Searched for surface outlet Does the system discharge sewage to drain ❑Yes ❑ No ❑ Performed hydraulic test the or surface waters? Searched for seeping in yard 1.10 Does the system cause sewage backup ❑Yes No ❑ Checked for backup in home into dwellinq or establishment? Do other situations exist that have the Excessive ponding in soil system/D-boxes ❑Yes I0 No potential to immediately and adversely ❑ Homeowner testimony impact or threaten public health or safety electrical unsafe covers etc.)? ❑ Examined for surging in tank Any"yes"answer Indicates that the system is an imminent "Black soil"above soil dispersal system t4D threat to public health and safety. ❑ System requires"emergency"pumping Does the system pose a threat to ground ❑Yes09 No ❑ Performed dye test water for any conditions deemed non- ❑ 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 list is not exhaustive, in sequential order,nor does it indicate which combinations are necessary to make this determination. Certification This form is to be completed and attached to the Summary Fort i of the Minnesota Pollution Control Agency's(MPCA)Compliance Inspection Form for Existing Subsurface Sewage Treatmen t Systems.Observations,interpretations,and conclusions must be completed by an inspector.Completed form must be submitted o the local unit of government within 15 days. Property owner name(s): t 4r n Property address: p W L1..J V Property owner's address(if different): County: Phone: I hereby certify that I personally made the observations, interpn Cations, and conclusions reported on this form and that they are correct. Name: Certification number: Business license name and number: Name of local unit of government: or Signature: , Date: 7 - 8 sts4 31 411108 1110Compliance Inspection Form for Existing SSTS 4/1/08