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�� 2/25/02 Water/WastewatE�r-IS7S4.31 , , �� ' .�� ,� � Compliance Inspection Form for Existing Individual Sewage Treatment Systems Minnesota Pollution �` Control Ac�ency Completion of ihis form fulfills the minimal requiremenfs o(Minn. Stat. § 115.55(2001)and Minnesota R. ch. 7080(?999). Please refer to local ordinances_for_olher requirements or information especially for complionce requirements for bedroom additions — � General: Date of Inspection: 1 Reason for inspection: ��-\� Property Owner(s) Telephone ( ) Person requesting inspectio O. � ✓��C p'(- Telephone ( ) Site Address 5.s S i City �'��1��_ Zip Code:�3� Fire No,/ Parcei No. County �'f Yl i ✓1 Township Legal Description Locai Regulatory Authority C� Date system constructed ��1$� System in �horeland Area: yes no System in Weilhead Protection Area: yes no System serving a MDH iicensed facility: yes no Local Permit # (if any),_ Systems built prior to April 1, 1996 and not located in Systems located in Shoreiand or Wellhead Protectlon Shoreland or Wellhead Protection Area or Serving a Food, Areas or Serving a Food, Beverage o�Lodging Beverage or Lodging Establishment Establishment, or systems Built after Mar�h 31 1996 s t e svstem an imminent threat to nublic health or Is the svstem an imminent t reat to publi�: health _ safe � (a yes aaswe�is an ITPHS system) or safetv? (a yes answer is an ITPHS system) -Discharge of sewage to the ground surface? YES 0 - Discharge of sewage to the ground surface? YES NO -Dfscharge of sewage to draintile or surtace waters? YES - Discharge of sewage to draintile or surFace waters? YES NO -Sewage backup into dwelling? YE5 O - Sewage backup into dwelling? YES N� -Sltuation with the potential to immediately and -Situation with the potential to immediately and adversely impact or threaten public health or adversely impact or threaten public health or safety? YES � safety? YES NO Is the svstem failinq� (a yes answer is a failing system) Is the system failing? (a yes answer is a failing system) -Less than TWO feet of vertical separation between - Less than THREE feet of vertical separation between system bottom and saturated soil or bedrock? YES system bottom and saturated s�il or bedrock? YES NO -A seepage pit, cesspool, drywell, or leaching pit? YES 0 -A seepage pit, cesspool, drywell, or leaching pit? YES NO Is_the svstem non-com�liant� Is the svstem non-comaliant� - is the system regulated under a monitoring plan or - Is the system regulated under a monitoring plan or operating permit? (if no,go to page 2) YES 0 operating permit? (if no, go to pa,qe 2) YES NO If yes, !f yes, - Has the required monitoring taken place? YES NO - Has the required monitoring taken place? YES NO (If no, ihe system is non-complying) (!F no, the system is non-complying) - Does the monitoring indicate that the system meets - Does the monitoring indicate that the system meets performance expectations? YES NO performance expectations? YES NO (If no, the system is non-complying) (Il no, the sysfem is non-complying) Page 1 of 2 wq-wwists4.31 T 'd Z6ZE-ELS (ZS6l punjpamS 4�oC e�0 �90 90 Si ��d