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10/16/2008 20: 42 9527586278 ADVANCED ONSITE INC PAGE 04 <br /> � <br /> i <br /> i <br /> Parcel number. _ _ __ System status: �Compliant � Noncompiiant I <br /> (as determined by this form) � ! . <br /> i <br /> � <br /> ' Hydraulic P�rfn�mancp and Oth�►r Gamplian�e � <br /> Compliance Issue #1 of 4 � <br /> �ate of o�servation: �Q�,��� Reason for observation: �lJ�y1�% I�r,�� . <br /> This fo�m�expires upon next inspection or in three years,whichev2r occu�s frst: T,.��'^�j� ` ^' <br /> � _,�. <br /> �Complianco questi�onslcriteria: (Required) Verification Al►ethod�: (optiona�) <br /> (Chcck the appropriate 6ox <br /> — �-»--,.-...�- ---....... . (C.heck�he a,opropnaCe box) <br /> '�oes the system discha�ge sewagc to the ❑ Yes �`Na �Searched fo�surface outlet . � <br /> _�rou.nd surface? ' � <br /> �oes tl�e system discharge sewage lo drain [(Ycs No � �°'�o'T"ed hyd�aullc lr�� , <br /> tile or surFace waters? � _ ��,Searched for seEping in yard � <br /> E�ues the system cause sewage Dackup ❑ Yes �No � Che�ked for backup in home � <br /> into dwellinq or establishment? � ,,,,_ _ ❑ Excessive ponding in soil system/D-6oxes � <br /> i <br /> Do nthPr eih��ti��s exist that have thQ (]Y0e �No p <br /> potential to immediately and adversely �Homeowner testimony + <br /> i <br /> Impact or th�eaten public health or safety ❑ Examined for surging In tank ' <br /> ��+alnr.trir..al, �msafa cevors, vtc.)� . � i <br /> "Black soil"above soil dispersal system � <br /> Any"yes��answe�ind;cates llrat the system is an imminent <br /> � threat to publ;c health andsafety. ❑ System rrquires"emer9ency"pumping . <br /> " � —� — ❑ Porfarmed dye test <br /> Does the system pose a threat to ground ❑Yes Na �Othe�: ��C �� f � �(�Y� <br /> water for any condition,deemed non- ��— �� � <br /> �rotective as dote�mine�d by the inspector? � <br /> "YQs"indicates thatrhe system is failing to protect <br /> graund water.It'��yes�; descripe tne conditio� noted: ---'"'- -�- �`— <br /> "No standard protoco/exisrs. this l/st!s noF ax�austi�ry, <br /> - --- in.s�quantial order, nordossitindreate which � <br /> � combinations are necessary to rnake this determina l�;m. <br /> �ertificatian � <br /> 1 <br /> This form is to be completed and attached to the Summary Fv�m of the Minnesots Pollui�i�n f:�rstrnl Ar�pnr..y's(MPCA)rompli� co ' <br /> Inspection Fortn for Existing Subsurface Sewage Treatment S�s#ams.Observations, interp�Etations, and conclusions must�:�e <br /> completed by an inspector, Comploted form must be submitt�d to the local unit of g�vernment withfn 15 days. f� <br /> c� C, I. <br /> :"• Property�osn�ner,name(;); � C . ��n�� V' <br /> r- <br /> ii <br /> f�ropEriy address: �jl.'� _rj .S' ' ,Z ► <br /> - - _��e.�lg�� �/�,. _1_�-�3J�►� <br /> PropErty owner's address (if different): � � <br /> CouniY: .._.... ��If/�e%2i��,_ � Phnnp� 7 '� / �J�- <br /> r ; <br /> 1 hereby certify that I persona!!y made 1i�e observations,,inteq-�r�fations, and conclusions ir�ported on this form and that they are l <br /> correct. <br /> �J i <br /> IVame: /J l Certificatlon number: y� ; <br /> 13usiness licensa name and nu r: �!/ rL �� y1s �j�„�� _ ��� �,i.� <br /> IV2me of local unit of g�v t; _ <br /> �--_�... <br /> Si�n2ture: � _ _...,,,,.�— Date; _✓��� "Q . <br /> � <br /> , <br /> wq-wwfsts�-3f Comp(lonce Inspectfon Form for,ExisCing 5�IS � <br /> 4!9/08 <br /> . 1 <br />