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� , w � <br /> Compliance Inspection Form for Existing <br /> � Individual Sewage Treatment Systems <br /> � <br /> This form reflects the requirements of the 1996 version of MN Rules Chapter 7080 <br /> Minnesota Pollution Control Agency <br /> Note:Local inspection standards may be more or less restrictive than the state requirements. These differences must be made available by the Local <br /> Unit of Government. ' <br /> � <br /> Date of Inspection: � <br /> ; <br /> Property Owner(s)�-. , � ,�`, , , ._� � ,:. . Telephone( ) <br /> Person requesting inspection(if different than owner) Telephone( ) <br /> Reason for inspection: ,;' . ' <br /> Site Address ,� ,� City �- ,�, c-�� <br /> Zip Code Unit of Government Regulating this property :'f ,--�- ,�' <br /> Fire No. Parcel No. Township Name � ? <br /> F <br /> Township Range Section Quarter <br /> (Check appropriate sewer system component and indicate location on site sketch). F <br /> Tank s : Soil Treatment System: Other(briefly describe�: Flow Meter <br /> `�=Septic tank �`, Rock trench _Alternative system <br /> _Aerobic tank T Gravelless pipe t�ench _�xperimental system Yes �No <br /> _Pump tank Chamber trench Warrantied system If yes, <br /> Holding tank Seepage bed Exp.Date: <br /> Other Mound Other <br /> _At-grade <br /> ti <br /> �stem Classification <br /> System Built Prior to April l, 1996 and not Located in Any System located in Shoreland or Wellhead } <br /> Shoreland or Wellhead Protection Area or Serving a Protection Area or Serving a Food, Beverage or <br /> Food, Beverage or Lodging Establishment Lodging Establishment, plus all systems Built after ; <br /> April 1, 1996 <br /> 5 <br /> Is the sXstem an imminent public health threat(IPHT)?U�grade Is the system an IPHT? Upgrade <br /> 1.Discharge of sewage to the ground surface? YES NO 10 mo 1.Discharge of sewage to the ground surface? YES NO 10 mo <br /> 2.Discharge of sewage to draintile 2.Discharge of sewage to draintile or <br /> or surface waters? YES NO 10 mo surface waters? YES NO 10 mo <br /> 3. Sewage backup into dwelling? YES NO 10 mo 3. Sewage backup into dwelling? YES NO 10 mo 4 <br /> 4. Situation with the potential to immediately and 4. Situation with the potential immediately and <br /> adversely impact or threaten public health or adversely impact or threaten public health or � <br /> safety? YES NO ]0 mo safety? YES NO 10 mo <br /> Is the system failing? Is the system failing? <br /> 5.Less than TWO feet of vertical separation between 5.Less than THREE feet of vertical separation between , <br /> system bottom and saturated soil or bedrock? YES NO LGU** system bottom and saturated soil or bedrock? YES 'NO LGU** <br /> 6.A seepage pit,cesspool,drywell,or leaching pit? YES NO LGU** 6.A seepage pit, cesspool,drywell,or leaching pit?YES NO LGU** <br /> s <br /> ** LGU=Local Unit of Govemment ordinance must specify the time period within which the system must be upgraded. <br /> 1, <br /> STATUS OF THE SYSTEM � <br /> r <br /> Based on the compliance criteria above the,system status is (check one)CI in compliar�ce(functioning)� failing�an imminent threat <br /> therefore,this document is a(check one)�Certificate of Compliance d Notice of Noncompliance. <br /> , <br /> ``I <br /> i <br /> Page 1 of 2 <br />