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04/26/2610 67:28 9528733112 PAGE 02/05 � � _ ..,-' P2rCel number: ___ ___ � `_ System status: �Compliant ❑ Noncompliant (as determined by this formJ Hyd�aulic Per#vrmance and Other Compliance Compliance Issue #1 of 4 ' Date�f observalion: � U Reason for observation; �_� ^y! _ This form expires upon next inspection or in three years,whichever occurs first: Compllance questionslcriteria: (Required) Verification Method*: (Optional) (Check the a ro rlete bex (Check the approprlate box) Does the sysiem discharge sewage to the ❑Yes � No �( Searched for surface outlet yround surFace? �-- D�es the system discharge sewage to drain ❑Yes �No � Performed hydrautic test tile or surFace waters? ! ��Searched inr saeping in yard Does the system cause sewage backup ❑ Yes �No ❑ Checked for backup in home intv dwellin or establishment? � ` ❑ Ex�essive ponding in soil system/D-boxes Do other situations exlst that have the ❑Yes �No � womeowner testimony potential to immedlately and adversely � impact or threaten public health or safety �'{ Examined fo�surging in tank clectrical, unsafe covers,etc.? ` Any"yes"answer Indicafes that fhe system!s an lmminent � �B�ack soil"abowe soil disporsal sys[em threat to pub!!c hea/th a�d safety. ❑ System requires"emergency'pumping —"'" � ❑ Performed dye test �O;'� Ooes the system pose a threat b ground ❑Yes No / ,,��, water for any conditions deemed non• ! � �he�� _-.�.._�9_�"1d-___ . ...�v��:�_ rotective as dete�mined b the ins ector? r7 _ �71►�' _ �//+� C f��, ��a�� �_ —��,---._._.. "Yes"lndlcates rhat the system is failing to protect `��d � �%,c�__ ground water. If"yes'; descrlbe the conditlon noted: - - � 'No stendard protocol exisfs. This list is not exhaustrve, •• - in sequenfia!order, noi does it indicate wl�rch ___ _ combinafions are necessary fo make tl�is determinatior�, Certification This form is to be completed and attached ta the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compfiance Inspection Form for Existing Subsurface Sewage T�eatment Systems. Observations,interpretations, and conr,lusions must be completed by an inspector. Completed form must be submitted to the local unit of government within 15 days. PropeRy owner name(s); � � 1,� (j e � —•-- ••— -w..,�^-•--- --- . _._._....._ Propertyaddress: � 1�1� ,. �� __......._.+ .__._.. Properly owner's address(If dlfferent): � County: �.(�(1.�0 � t '�� _ Phone: I hereby certi�y tha(1 personally marle�he ob5ervations, interprc�ations, and conclusions reported on this form and thal they are correct. Name: , �O j� '��1u�1�1 _ _� Certification number; 1��J-f ------ - --.._......_ ausiness license name and number. �-U„y��U(�� _ • ��S _,`�L �(}� • „V _____ or � Name of local unit vemment/ -- � .......------ Signature: � J ^ . ---- - .. Date: �!._......__._.....,.. ._, wq-wwists4•31 CORIOIIU�C2 1f7MPrtinn Fnrrn fnr Frictirtn CCT<