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Parcel number: ' System status: R Compliant p ID Noncompliant (as determined by this form) Hydraulic Performance and Other Compliance—Compliance Inspection Form for Existing SSTS Compliance Issue#1 of 4 Date of observation: i J--1-3.0)o Reason for observation: 'p-q {. -( Le,«,. This form expires upon next inspection or In three years,whichever occurs first `f- Compliance questions/criteria: (Required) Verification Method*:(Optional) (Check the appropriate box) (Check the appropriate box) Does the system discharge sewage to the 0 Yes ®No ground surface? IN Searched for surface outlet>.ro Does the system discharge sewage to drain 0 Yes 0 No ❑ Performed hydraulic test tile or surface waters? ® Searched for seeping in yard 140 Does the system cause sewage backup ❑Yes L No ❑ Checked for backup in home Into dwelling or establishment? is Excessive ponding in soil system/D-boxes 140 Do other situations exist that have the 0 Yes ®No Potential to Immediately and adversely ❑ Homeowner testimony impact or threaten public health or safety ❑ Examined for surging in tank (electrical,unsafe covers,etc.)? Any"yes"answer Indicates that the system Is an imminent ® °Black soil"above soil dispersal system 14r) 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- 0 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 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): gq�gvp� 1' Property address: cda O So. O\,q CAN 'Q+n. 410140 Property owner's address Of different); County: j. 4„j Property ovmer phone: 9 5 2-99 S 'ZD4 I hereby certify that/personally made the observations,Interpretations,and conclusions reported on this form and that they are correct. Name: . r., Certification number: (oar) Business license name and number: S-9�( -{t).�(4 WS C L 1 C, 3 q y 'VIA ')i3—'t' —S S tAn or Name of local unit of government: Signature: , - Date: I j—i%.9,(9)0 www.pca.state.mn,us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats wq•wwists4-31 • 4/24/09 Page 2 of 8