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Parcel number: 27-118-23-44-0008 System status: ❑ Compliant � Noncompliant <br /> (as determined by this form) <br /> Hydraulic Performance and Other Compliance <br /> Compliance Issue #1 of 4 <br /> Date of observation: 6/10/9 Reason for observation: Real Estate Transaction <br /> This form expires upon next inspection or in three years,whichever occurs first: 6/10/12 <br /> Compliance questions/criteria: (Required) Verification Method*: (Optional) <br /> Check the a ro riate box (Check the appropriate box) <br /> Does the system discharge sewage to the � Yes ❑ No � Searched for surface outlet <br /> round surface? <br /> ❑ PerFormed hydraulic test <br /> Does the system discharge sewage to drain ❑ Yes � No <br /> tile or surface waters? � Searched for seeping in yard <br /> Does the system cause sewage backup ❑Yes � No ❑ Checked for backup in home <br /> into dwellin or establishment? <br /> � Excessive ponding in soil system/D-boxes <br /> Do other situations exist that have the � Yes ❑ No � Homeowner testimony <br /> potential to immediately and adversely <br /> impact or threaten public health or safety � Examined for surging in tank <br /> electrical, unsafe covers, etc. ? <br /> ❑ "Black soil"above soil dispersal system <br /> Any"yes"answer indicates that the system is an imminent <br /> threat to public health and safety. ❑ System requires"emergency" pumping <br /> ❑ Performed dye test <br /> Does the system pose a threat to ground � Yes ❑ No <br /> water for any conditions deemed non- ❑ Other: <br /> rotective as determined b the ins ector? <br /> "Yes"indicates that the system is failing to protect <br /> ground water. If"yes';describe the condition noted: <br /> *No standard protocol exists. This list is not exhaustive, <br /> Tank is severly rotted dew to septic gases it is possible that a in sequential order, nor does it indicate which <br /> collapse could occur. combinations are necessary to make this determination. <br /> Certification <br /> This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compliance <br /> Inspection Form for Existing SubsurFace Sewage Treatment Systems. Observations, interpretations, and conclusions must be <br /> completed by an inspector. Completed form must be submitted to the local unit of government within 15 days. <br /> Property owner name(s): LUCILLE M OFFERMAN TRUSTEE <br /> Property address: 1669 NORTH FARM RD LONG LAKE MN 55356 _ _ _ _ _ <br /> Property owner's address(if different): <br /> County: Hennepin Phone: <br /> I hereby cerfify that 1 personally made the observations, interpretations, and conclusions reported on this form and that they are <br /> correct. <br /> Name: Mark J Hayes Certification number: R5013 <br /> Business license name and number: Minnesota Geotechnical Services, LLC MPCA#L3203 or <br /> Name of local unit of government: Wright County <br /> Signature: M�/ ��� Date: 6/16/9 <br /> wq-wwists4-31 Compliance Inspection Form for Existing SSTS <br /> 4/4/OS <br />