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07121l,2008 10: 53 9528733112 PAGE 02/05 <br /> � <br /> i <br /> � <br /> Parcel number: Sys em status: Com liant <br /> -, p ❑ Noncompliant <br /> (as etermined y t is form) <br /> Hyd�aulic Performance and ather Compliance <br /> Campliance Issue #1 4 � � <br /> Date of observation; Reason for observation: ��$_,_ <br /> This form expiras upon next inspection or in three years,whichever pccurs fi t� � <br /> Compliance questions/criterfa: (Required) V rification Method': (Optional) <br /> (Check the appro nate box) Check the appropriafe box) <br /> Does the system discharge sewage to the ❑Yes �No <br /> �round surface?, Searched for surtace outlet <br /> PerFormed hydraulic tcst <br /> Qoes the system discharge sewage to drain [] Yes �No <br /> tile or surFace waters? Searched for seeping in ya�d <br /> Does the system cause sewage backup ❑ Yes �Nv Checked for backup in home <br /> into dwellin or establishment? Excessive ponding in soll system/D-baxos <br /> Do other situa6o�s exlst that have the . ❑Yes '�No Homeowner testimony <br /> potential to immediately and adversely <br /> impact or threaten publlc health or safely Examined for surc,�ing in tank <br /> electrlcal, unsafe covers,etc, 7 "Black soil"above soil dispersal system <br /> Any"yes"answer indlcates thaf the systelll is en imminent <br /> threat fo pub!!c health and safety. System requires"emergency'pumpfng <br /> -- Performed dye tesi <br /> Does the system pose a threat to ground [1 Yes ❑No Other; <br /> water for any conditivns deemed non- ----"'---------'- -� � � <br /> rotective as determined b the ins ector? <br /> "Yes"indreates chat the system is fafling tQ protect <br /> ..—-----------.. .. ..._. . . . <br /> ground water /f"yes", descrlbe the candrUon noted: . <br /> " stsndsrd protocol exists. Thrs fist is not exhauslive, <br /> - in sequentia!order, nor does it rndicate which <br /> c mbinations are necessary to make lhis determinatian. <br /> Certification <br /> This form is!o be completed and attached to the Summary Form of th�Mi�n sota Pollution Control �lgency's (MPCA)Cvmpliance <br /> Inspectlon Form for Exlsting SubsuKace Sewage Treatment Systams. O servations, interpretations,and conclusions must be <br /> completed by an inspector. Completed form must be submitted to the local u it of government within 15 days. <br /> Property owner name(s): �d/�Q ��t� <br /> _ �',�"` , _ ,:_.�_,..�._._....,--• ---... ........_....__._...... . <br /> Property address; Co � a / 1'`10� '.'N---^—� C' ._--.-- .--.._._. <br /> Property owner's address(It dlffe�ent): <br /> Counry; �Yr�? i�(3�.Y� Pho e: -,--- <br /> I nereby certify that 1 persona!!y made ihe observations, inteipretations,and onclus�ons reported on this form and that they a�e <br /> correct. <br /> Name: _. �� ��1����C� Ce iFicaGon number: �q{���.._________. _ <br /> Business license�ame and number: ,_,.S(,L2G)I Uf1� 1 Oa � ______ or <br /> Name of local unit of o rnm� <br /> Signature: Date: �__ �f (J '� <br /> Wo•wWisi54•31 rmm�linn�o Incnerrfnn Fnrm fnr Fric�ino CCTC <br />