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69/23/2e11 15: 52 9528733112 PAGE 02/05 <br /> Parcel number: ____„_.,. , ___ �. SY om status: Compliant ❑Noncomplianl <br /> —� (as determrned y is rorm) <br /> Hydraulic Perforrnance and Other Compliance <br /> Compliante Issue #1 of 4 <br /> Date of observation: �a ( Reasan for observation: -- — <br /> This form expires upon next inspection or in three years,whichever occurs i�st: —_-�.�---• ---- -- <br /> erification Method': (Optional) <br /> Comp�iance questionslcriteria: (Required) Check the e ro riate box <br /> Check the a ro riate box ( PP p � <br /> Does the system discharge sewage to the [� Yes No Searched For surface outlet <br /> �round surface7 � Performed hydraulic test <br /> Does the system discharge sewage to drain ❑ Yes NO Searched for seeping in yard <br /> til�or surface waters? <br /> Does the system cause sewage backup ❑Yes No <br /> (] Checked for backup in home <br /> into dwellin or establishment? [] Excessfve ponding in soil systemlD-boxes <br /> Yes No ❑ Horneowner testimon <br /> Do other situations exist that have the Y <br /> potential to immediately and adversely � Examined for surging��tank <br /> impact vr th�aten public health or sai�ety <br /> �electrical unsafe co�ers etc. 7 p "Black soil"above soil dispersal system <br /> Any"yes"answer ind�cates that the system Is an imminent � System requires"emergency'pumping <br /> fhreat to publiC heaf�h and sefely. <br /> ❑ Pe�Fortned dye test <br /> Does the system pose a threat Uo ground ❑ Ye3 No ❑ Other _._____—. _.—__.. ..___._... <br /> water for any conditions deemed non- _� <br /> _ rop tective as determined b the Ins ectoR � <br /> "Yes"ind;cates [ha!the system Is farling to protect �--�—� � <br /> grvund water. If"yes'; descrfbe rhe cond!l/on noted: •No standard prvtocof exisfs, This list is not exhavstiv�, <br /> in saquential order, nor does it indica(e which <br /> combrnalrons are r+ecessary to make this determination. <br /> tertification <br /> This form is to be �ompleted and attached t�the Summary Form of the M nesota Pollutlo n erpretat og sn and conclus�o smmust be <br /> I�spectio� Form fior Exlsting Subsurtace 5ewage Treatment System , Observatians, <br /> completed by an inspeccor.Completed form must be submiried to the lo I unit of government within 15 days. <br /> Property owner name )' _ _ •^--•----- -- ---- .. . <br /> Properry address: —�� � � <br /> Property owner's address (if d�tfenent); <br /> hone: , . -----=-- <br /> County: <br /> 1 hereby certlfy that 1 personally made the observations, inferpretations, nd conclusions reported on this form and fhat ihey are <br /> correct. <br /> Name: y~�_J�JC���u— . Certlfication number, �p�-- . .. ----� <br /> F3usiness license name and number: <br /> � a . -- --..- or <br /> Name of local unit of emme : � �� ^ <br /> Date: ---- <br /> Signatu�e: „ � —� —.._..._.... . <br /> ,.,.. ..,,.,;���w_a+ Compfiance lnspection Form for Existin4 SSTS <br />