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� _ ,.- . �� ' ; 2/�5/07_ � Water/Wastewater-ISTS4.31 /`�� 0,1�1�.111 I�fIIG�.�I��71��1Uii �' 1"I11 ��" �)C��II7C� ��+ Tn�isvici�sal �ewage T�r�� (s1'1� ��►'S��@T1� �linne�ota Poplutimrn �b"r � � Cae��rol Agen�cy Completlon of this fomi fulfi!!s fhe rrilni/nalireyuirements of�L1inn..Staf: § 1 5.55(2001)and Minnesota R. ch. 70�40(1999�_ Please refer to local ordinances for other re .ufcements.orinformation es eclall for.co liance rec uirements.for bedroom addl'tfons_ � � General~ �ate of]fr�spec�ion: 1 t-1D-qrj !Reason for inspection: �1 � �►1� Property Owner(s) AI..U�I?..� (�-�"c�'�S'� � T�9ephone (�Sz) �?S-'3�Sp� Person requestin� 6n�p"ec:tlo�u . ' S �rvi Te9ephone ( ) 5it�Addre�s 4I 4S S 'QA`��t��a;� '�� City G�o�.s�c7 �i� Cod� Fire tVo./ �arcel 1Vo. � • ��Q� ,, h,►. � O "d'orrvras9�ip IL�gal De�criptior� � � Local Regulatory/-�utFaority G-t�C'� L�'� fJ'S�t� � . Date system cortst�uc�eil � 4^��?'� �(ca �'}(� ;;ystem in� oreland 1�I'ea: �ies o System ita Well.heacl Frotectian Area: yes �5yst�en �erving , Y�1�)Fi licensecl f cility: yes � Locat Pea-rtait# ('sf any) . Systems built prior.to Aprii i, 1996 �nd no�loc�3ted fn Sy.stems'located in Shoreland;or Welihead.Protection Shoreland or Welihead Protectfon�l�rea or Setving a�Food, Areas o�•SeNing.a Food;Beverage.or�Lodging Beverage or Lodging Establishment Estab�ishment, or systems Quilt aYt�r = March 31, 1996 Is the sy�stem an imminent threat t�o puF�lic health or T t e s �ste an im inen the�ea to �ublic health safe ? (a yes ansive�is an ITPHSsyst`emJ� . �o safe 3' (a yes answer is an ITPH.S systemJ � � - Dfscharje of sewage to the ground surface? YES NO - fscharge ofsewage to the ground surtace? YES CNO� - Discharge of sewage to dralntife or surface water�? YE5 NO - fscharge of sewage to dralnttle or surface waters?YES �(NQ� -Sewage backup fnto elwellfng? � YES NO - ewage..backup Into dwelling7 �YES (NQ� -Situatfon wfth the potientfal tio fmmedlately and - Itua.tton wlth the potentfal to immediately and adversely fmpact or threaten public health or ' adversely lmpact or threate� public health or safety? . YE5 NO safety7 . YES NO Is�he sustem failinq? (a yesanswer,is.a failingsyst�m) T f:he s t�rm-failin ? (a yesanswerisa fai/ingsystem) -Less than T11�fo feet of vertical.separati,on betw�en� , - ess than TFi�EE feet of vectical separatinn�betweEn systtm I�ottom and�afurated soil or�tiedrocic? YES NO syster'rt bottom arid saturated soll or bedrodc? ES NO -A seepage plt, cesspool,dtywell,orleaching pIt? YES 'NO - seepage pit,cesspool,drywell,or leaching pit7 ?� YES NO Is th�sv�tem no.n-comnli�nt�' �. � � T he �s e � �or- o lian - ls the system regulated under a moiiitoring ptan or • - Is� the� system�regulated under a .monitorin.g plan operating permit? (if no,.go to page 2) YE�3 No � o erating permit? (if no,go fo page�2) � YES 1� l�yes, . . � ' If yes,. - - Has the required moniloring taken pPace? YE:> NO - as the required monitoring taken plare? � YES NO (If no, the sysfem Is non-complying) ' f no, ihe syst�nt Is non=cciinplying) • ' . .' ', - - - Does.the monitoring indicate,.that the sysferri meets -� = oes�the monitoring indicate�thaf the system meets perfiormance expectations7: `� �° - • ��`'YES N.O �' ' � peYfoCmat�cr�ei�pectatiori.s? YES NO .... ..,. . .. . .:...-. ��-' PY 9) .. .,. . (If�no, :the sysfem is non-com 1 in • � � � � (If no, �fhe sy'stem'is non-complying) � _,,, ' .: ' . � . ' Page 1 of�2. . • wy-wwists4.31 . � .