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11/19/2011 04:32 7634975011 SPTESTINGINC PAGE 05/07 <br /> Parcel number �_ „_ _ _ Syst�m status: � Compliant (�Noncompllant <br /> (as defe»r�ined by t�his form) <br /> Hydraul�c Perforn��nce ar�d pther Compl�an�ce � Compliance /nspection Form torExisting SSTS <br /> Compliance Issue #1 of 4 <br /> I�ate of observatlon: �L.�� ��p�, Reasvn for observation� � y _' <br /> This form expires upon next inspAction or in three y�ars, whichever occurs first: <br /> Complianc�e q�uestions/cr�teria. (Required) Verifpcation Method'; (Optional� � <br /> _„Check th��riate box � (ChQcl�the app�vp�ate box) <br /> Does the system dlscharge sewagE to the ❑Yes (� No ❑ Searched for surface outlet <br /> __ground surface? <br /> Does the system discharge sewage to draln �'Yes [� Nv ❑ PerFormed hydraulic test <br /> „tile or surFac�waters?, __ u � Searched for seeping in yard ►.kt1 <br /> Does the system cau�e sevvage ba�kup 0 Yes �J No ❑ Checked for backup in home <br /> into dwell�or establishment9, <br /> - �- � Excessive pondfng in soil system/Q-boxes ►.�p <br /> Do othe�sltuations ezlst that have the ❑Yes � No <br /> po�en�ial to immedi�tery and adversely ❑ Homeowner tesUmony <br /> lmpact or threaten public health o�safety ❑ Cxamined for surging in tank <br /> �efectrical, unsafe covers, etc�? <br /> Any"yes"answer indicates lhat the system is an imminent � "�lack�soil"above soil dispersal system � <br /> threat to public heafth and sarety. ❑ System requires"emergency"pumping <br /> ' ,. ..'. ... _ ❑ Perfonned dye t�st <br /> Does the system pose a threat to ground ❑Yes [� No <br /> water for eny conditions deemed non- ❑ Other: __. � <br /> _protective as det�rmined by tho i. nspector? _� ` � ' <br /> "Yets"lndicetes that the sysfem Ps iailing t�o protpct � <br /> grou�d water.If"yes", describe t�he cond;tion notsed: " ••� • <br /> `No standard prah�co/ox�sts. Thls list is not exheus�ive, <br /> • • ^-•--� , in sequenfial order, nor does if indicai,cc�r wl�lch <br /> _ _ __y T cor►lbinetlans�r�necessary t�o make this determinallon. <br /> Cer�ification <br /> This form is to be campleted and a#tached to the Summary F'orm of th�Minnesota Pollution Control Agency's(MPCA)Compllance <br /> Inspection Form for�xlsting Sub�urFace Sewage Treatment Sys#ems. Observations, interp�etations, and conclusions must be <br /> cnmpleted by an inspector. Completed form must ba submltted to the Iocal unit of government within 15 dAys. <br /> Property owner name(s): G�___,._ '�,�L �.5 T, T� _1V.. ^ <br /> Froperty addres,s: �p .�.'�11���-.�\_D�g�,..},.1 � .. <br /> Property owner's address(If dif{erent): <br /> County: ���,.�,���1 _,.._. .. Property awner phon�: ��( Z - ���9 3 _.. _ _„ <br /> ,� __, <br /> I hereby cert!!y fhet 1 pmrsonally made the obse►vations, Interpret�aP�ons, and canclus/ons report9d on Phls form and ihet they are <br /> correct. <br /> Name: _S�� <br /> .��L•l�ar,S�1a1�Ar1,�G_'�`"�_, � Certlfication number: , le��7 <br /> Business license namo and number. S � Q���o h,1 L� 1�1 C , '�-+_4;,� �3'�7'�'� '(�y�� �7�o'�� �c�� ,�a��or � <br /> N2me of local unit of government: <br /> /� ^- •� -�-- <br /> Signature: �� 7J J,,..-�f� ...,� 4 Date: .,. _, <br /> - --� .., ����:a 1 � <br /> www,pca.state.mn.u5 • 651•Z94�6300 � 800-657-3864 • TTY 651•282-533Z or 800•657-3864 • Avai�able in alkernalive formats <br /> uw+_����.:iL�/ 1/ . A/'1 J 111f1 ' <br />