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Minnesota Pollution Control Agency (MPCA) <br />Inspection Form for Existing Septic Svstems <br />DATE OF INSPECTION: /� TIMS, 01, WEATHER COXDiTIONS Ld ISTS PERF MIT NUMBER: <br />gf_ASO\ FOR I�Sg�r'T10\ IDE\TiFICA�Q` <br />()eedrocn addincin Property OHner(s) J U f I l� �LtQ4S�� Telephone (61. <br />1) varience Site Address 50 C1 ISTEole jgeL f City YW X-1 L4/Al <br />OCor..ptaint Zip Code County HAA4 <br />$Propem Transfer kbuyer cr $el:er) Fire No. owosb:p Nume <br />() Ot,`.tr Is system openee up? 1� (D Furl Partial ContraCorflnstallrr name: <br />Area aith tc:t_ ord:nance Y IJ Township Rsnize Sectior. Q_orters <br />i S 110� HAS •(s! ever been p+ygped' (f� \ 1 Mr System Built: l <br />If Yes, ho•+ oRe::? 17`1 1 for what :Cason: outir+eiy'Q asertten: backL;;o sluggish pt_ahtrg Oether <br />Any repair doni on sysiern? Y What Wren ,By w`o <br />Usage: C eh:r'c%ublishrert Odwe ling Oseasonal O other No.. 3edroorils Nc. of c;cupants <br />Water using appliances: $rClou :s washer)4(Dishwath::Gar:age dispcss:'hir:;ool ba `. 1Vatt: cenditior,:-g t nit GSe:f•::eanir.g hu+,,::ifi:r in `t rye <br />Msrest Surface Rater: = It from which ty;: ofiur*ue water <br />Check appropriate sewer system component end ir.=icate location on site sket:h on bat': of for -.;- <br />Tank (sl: Tjnkfs) Material: Soil Trestment.9y=: <br />Sept:: :ink Fiberglass _ rock trench _ ai'ernativ: system (identity ry;,c) <br />_ Aer;bic lank � Plastic _ grave! less L-ench � exzerimental syveri (identir: rype) <br />_ P;:Tp ta:.k Metal _ chamber trench c .ter (identify type) <br />—Holding talk '4CCnerete _ s:epzge bed <br />Otter Other x mound <br />O,IDoO, o at•gradc �.,.Ij7 t <br />Tank(s) Sarre. I eats Soil treatment area size(s): A0 sq. ft. Depth ofsystcn botterr. from grade: zll Setback: > Sa <br />CAt1IPLIANCE INSPECTION" <br />IS tilere or t•ae tti!•e ever been any evidence of: R s- 2ns Exglain <br />Discharge cf sewage to the ground surface? YES NO ' <br />Discharge of sewage to a surface water? '+iS <br />A seepage pit, drywell, :esspool or leaching pit? ES . 0 <br />Less than three fee: of vertical separation between :he soil treatment system .M I <br />boom and saturated sot i or bedrock? `• ES `ti0 Il LtD� <br />Sewage ba:kup into dtk. Citing or other estab:ishmert ;.: esen::v occu- ng? ' 1-ES <br />Situations with *,he potential to immediate:y and ads ersely :.npzct cr :area:en <br />public hca%h or saferyl YES ti0 <br />if YES was v..swered for a'.y of the above ques*.=s,'!:e system. :s failini; according 'o Minn. R. c`.. 7080.0060. <br />(if wet; seti;acks are violated, a pc:entizi itnmirnt threat to pub:f: health or safety may exis:) <br />STATUS Or TH Z SYSTEM <br />Based on the compliance inspection conducted above the system status is iN _DIi�',/�G 7 , therefore, <br />s �- (Cho se: it c�o j'� "ence OR fa Ling OR feilirg/i-ttni-_nt th eat) <br />this document is a l`F���f G �l� �L1�11J� } <br />(Choose: CertiS:ate of Compliance OR Notice of Ncrt:ompiivxe ) <br />LEA7IFICA SfON <br />I hereby certif; as a state of.vinnesota licensed Inspector, Designer! or Qualified Er-..p:ogee that a:y obsen•ations recorded on :his form are accurate <br />as of tie Ca:e at :he top of this form for the site stated above. 1 hemby certify that all inspection wo.k was completed sc:crding to ZDPECeb!: <br />requirements. No det:: mir.ar:on of future hydrauIi: perfc.-insince cari be made due :o ;nl now•n conditions during system cons, ruc.:on, fur tr: water <br />Lsage o%er the If oft" s; tern, abuse olfths ys::m , an�o: inadequatt ma:n:envice al: os ;hich will ad�ersel. affect the tote of he s; s:en. <br />lnspec:or's name �� N (print) Phone No.�O[�"�"CLicense aadlo: Registratie + *:u^..be- 2 <br />a, <br />.�ddtess Q Q <br />S'gnat,rc t-r Date �` l0 <br />