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r. <br /> • <br /> Minnesota Pollution Control Agency (MPCA) <br /> , r, r.:;. ,i, ' v Inspection Form for Existing Septic Systems <br /> DATE OF INSPECTION .of—I I" 1 U TIME: Iwo 0)7 WEATHER CONDITIONS: Oyt cC¢ ISIS PERMIT NUMBER: c,13�jr <br /> REASON FOR INSPECTION IDENTIFICATIOIVN <br /> 0 Bedroom or bathroom addition Property Owner(s) ,liti/ Al; I Ste'i) Telephone(O/d) .22 y-v�/O� <br /> ()variance Site Address Lice' [v v J/„ 1/ )(-/ City (10)/7 j;- <br /> ()Complaint Zip Code County 1 k' I 1/ F:i�,'i"") <br /> 'roperty Transfer Fire No. ,r/ Townshi e <br /> ()Other Is system opened up? (VN Full <br /> SYSTEM • <br /> Has tank(s)ever been pumped? CC) N Year System Built: /) G't') <br /> If Yes,how often? For what reason:'routinely 0 basement backup°sluggish plumbing 0 other <br /> Any repair done on system? Y 6 What When By whom <br /> Usage: 0 other establishmpOlwelling0 seasonal° other No.Bedrooms No. of occupants <br /> Water using applia lothes washer .Dishwasher�l Garbage disposal O Whirlpool bath O Water c1ondit�pning unit O Self-cleaning humidifier in furnace Nearest <br /> Surface Water: = 7 ft from which type of surface water 0 rivetO lak.0 streanO other IA.0-,`J i7-,.c. <br /> (Check appropriate sewer system component and indicate location on site sketch on back of forst). <br /> YTank(s): Tank(s)Material: Soil Treatment System: Other: <br /> Septic tankZ _Fiberglass 'ock trench alternative system (identify type) <br /> _Aerobic tank _Plastic _gravelless trench experimental system (identify type) <br /> _Pump tank Metal _chamber trench _other(identify type) <br /> _Holding tank oncrete— _seepage bed <br /> _Other _mound <br /> _at-grade <br /> Tank(s)Size: c -2/20-2/20 gals Soil treatment area size(s): ('l fro sq.ft. <br /> COMPLIANCE INSPECTION* <br /> Is there or has there ever been any evidence of: Response Ex lain <br /> Discharge of sewage to the ground surface? p <br /> YES <br /> Discharge of sewage to a surface water? � Z`'}'�� Y�, 411A seepage pit,drywell,cesspool or leaching pit? NO ��✓ NO <br /> Less than three feet of vertical separation between the soil treatment system <br /> bottom and saturated soil or bedrock? <0 NO <br /> Sewage backup into dwelling or other establishment? YES NO <br /> Situations with the potential to immediately and adversely impact or threaten <br /> public health or safety? YES NO <br /> *if YES was answered for an of the above Iuestions,the s stem is failin. accordinc to Minn.R.ch.7080.0060. <br /> . STATUS OF THE SYSTEM <br /> Based on the compliance inspection conducted above the s'stern s tus is //nf;t; ,therefore, <br /> i (Chose: in compliant OR failing ) <br /> this document is a Ne)(1c- � Qr f e n �IV�el/KC <br /> (Choose:Certificate of Compliance OR Notice of Noncompi'fance ) <br /> CERTIFICATION <br /> I hereby certify as a state of Minnesota licensed Inspector,Designer I or Qualified Employee that my observations recorded on this form are <br /> accurate as of the date at the top of this form for the site stated above. No determination of future hydraulic performance can be made due to <br /> unknown conditions during system construction,future water usage over the life of the system,abuse of the system,and/or inadequate <br /> maintenance all of - '_' will adversel .ffect the life of the system. <br /> Inspector's name . I/67 i' 1 ' )1 /) Phone No. 1.17 z <br /> yJ 9 License and/or Registration Number 0/26r <br /> (pease p int) <br /> Inspector's signature 6 <br /> �) 11 '11,4--------" Date / 7 9 <br /> (� <br />