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08/01/2008 05:33 7634975011 SPTESTINGINC PAGE 04/05 4 Parcel number. System status: ❑Compliant Noncompliant (as determined by this Dorm) Hydraulic Performance and Other Compliance Compliance Issue #1 of 4 Date of observation: _��1 -Q Reason for observation: _!W!%. v%Q%510 ^_ This form expires upon next Inspection or In three years,whichi ver occurs first: Compilance questionsicriteria: (Required) Verification Method": (Optional) (Check the appropriate box) (Check the appropriate box) Does the system discharge sewage to the ❑Yes H No ❑ Searched for surface outlet _q!9und surface? Does the system discharge sewage to drain ❑Yes ❑ No ❑ Performed hydraulic test the or surface waters? _ � _ Searched for seeping in yard 14o Does the system cause sewage backup ❑Yes IJ No ❑ Checked for backup In home into dwelling or establishment? ® Excessive ponding in soil system/D-boxes �Jq Do other situations exist that have the ❑Yes ®No ❑ Homeowner testimony potential to immediately and adversely Impact or threaten public health or safety ❑ Examined for surging in tank (electrical unsafe covers etc.)? "Blaclk soil"above soil dispersal system $4-0 Any"yes"answer indicates that the system is an Imminent threat to public health and safety. © System requires"emergency"pumping ❑ Performed dye test Does the system pose a threat to ground ❑Yes ®No water for any conditions deemed non- protective on- Other: rotec ve as determined by tie Inspector? y` "Yes"Indicates that the system is failing to protect ground water.If"yes". describe the condition noted. r' No standard protocol exists. This list Is not exhaustive, in sequential order, nor does it indicate which combinations are neoessery to make this determination. Certification This form is to be completed and attached to the Summary Fort of the Minnesota Pollution Control Agency's(MPGA)Compliance Inspection Form for Existing Subsurface Sewage Treatme Systems.Observations,interpretatons,and conclusions must be completed by an inspector.Completed form must be submitted the local unit of government within 15 days. Property owner name(s): W%"I.jN%4 nig } Property address: Property owner's address(if different): County: .-I.,- 1 Phone: 1 hereby cattily that i personalty made the observations, Interpretations,and conclusions reported on this form and that they are correct. Name: �Gl1��f, �j• $L�k1 vyt� s Certification number: Goa 7 Business license name and number. . , 11 9 r.1��2t�3�!��(o or Name of local unit of government: Signature: —~ y Date: wq-ww1sts4-31 Compliance inspection f=orm for Existing SSTS ejirna