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. 07r26/2005 09: 55 763498829e RUST S PERC TESTING PAGE 03 <br /> • 1/29/02 Water/Wa�tevraCer-ISl'S�4.31 <br /> � Compliance Inspection Fo for Existing <br /> Individuai Sewage Trea ent 5�/sbefns M�"1°�"��"�O" <br /> co�a�o�Aqenc�► <br /> Comp�/efiv�n of this fa,m!ulfiNs the minimal requlrements of Minn_ Stst§1 5.�5(2001)end Mlnnesvta R- QA_ 7080(1989). PlBese <br /> refi��M k�cal o►dlnences Ibr other i►e►nents or i►�lonneflan de for lan�e ulreme►rts�bedroo►n addrtions. <br /> S�i <br /> Dabe of Inspeclion: �/�(05 REASON fbr I on: Pronert.v Tran�fer <br /> p��y p�(s) n Telephone( ) <br /> p��,ep��;�; Telephone (612 j 2 -�0 92Z� <br /> 5ibe,Addre�: �Yslele d Clty: Zip Code 55359 _ <br /> Rre No./ Pa�oe! No. County: Townmhip: . <br /> �ega�De�criPtion <br /> Lrocsl ReguMEory�ulhorily: <br /> Date sysbem Construrbed: 8/03/83 __ S�I�bem in oreland Mea:� no S�Isbem in Wellhead <br /> Prob�cfion Area: yes � �ys�em servin�a MDH lia�sed fa Ilty; yes �L.Ocai Permit#(if arry) 7085 <br /> Systems built prlor G�April i, 1996 and not laat�ed in s laa�ed in Shor�and or Welihead Pro6Bction <br /> Shoreland or Wdihead Prob�tion Ar�or Servtng a Food, Ar�eas or Servfng a Food, Beve�or Lvdgirng <br /> Bev�erage ar Lodging Fstabl�shment Estabilshmerrt,or sysbe�r�s BufR afber <br /> March 31 1996 <br /> �(a y�s a�asra�r/s an 1TPHS sys�►nJ (e yes arxswt�r�en I7A�Ls s1�►I <br /> -Discha�e of sewage�the grvund�rFeoe? YES NO -Di rge of sewage�tl�e ground sUrfaoe? YES <br /> -Disdwrge of sewage tu dralndle or svrtaoe waters? YES NO arge of sewage Lo drair�tile or surf-dce wa�ers7 YE5 <br /> -Sewage badap inbo dwelling? YES NO baclwp ir�b dwdling? YE.S N <br /> -Sltuatlon wRh tt�e pobentlal tra Immedlatiely and - witlt tt�e pobendal m immedlabely and <br /> adver.�eefy impect or tt�reaben publk healtl�or ImP�ct ar tttreaten public health or <br /> � YF5 NO ? � (� <br /> (a yes arisrr�r�s a Fa1/ir�9 sy��mJ (a yes answ�r Is a fai/i�9 sYslem) <br /> -Less than 71A10 f�eet of vertlr�l s�aration befiNeen - tf�an THREE fa�of vettkal sepnration between <br /> syshem bottom and saturabad soil or bedrodc? Y6 NO botLr�n and satura6ed 50U or bedrodc? �NO <br /> -A seepage PI�oess�od,dMnel�.or leadting pit? YFS NO -A pl�►Ces�o�,drywell,or lead►in9 Pit? NO <br /> - Is the system regulabed under a moniUoring plan or - I the system reguiaCed under a monlbonng plan or <br /> operating permit? ('d no, go to page 2) Ye5 No ope '�9 P��?(��� 90 tp Pa9e 21 � � <br /> If�, If)re8 <br /> -Has the required monitoring taken place? YES NO -H the requfred moniboring taken plaoe? YES NO <br /> (!/n0,the sysfern!s►w►►-oanplYr►r91 (1� .�e 8Y��►�-�►'N�Yfi91 <br /> -The monitoring indic�te that the system meets -Th moni�ring indicabe that the system meets <br /> performance expectationa? Y� NO rformance expecCaidons? YES PIO <br /> (�f no, u,e system is�m�yf�) ( no, the sys�em is no►�n�php►�gl <br /> Page 1 of 2 wq-wwists4.31 <br /> I <br />