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, � <br /> _ ,--.. <br /> - i 2/25/0? � Water/Wastewater-ISTS4.31 <br /> ��,ra�ja1��l�c�.�t��p�e�fiA�t� Fs�d'�11 �'��" �9�D��ii�� <br /> -�•--.�:-� Ti1�9�I6�I.11�At ��V61�[�E: �'t'��1�I17C':�"1� ��'Sfi�6T➢� n7inne�ota PoAlutioe� <br /> � ; <br /> _ � . Cos��rol�g�¢�� <br /> Comp/etlon of this form fulfiUs fhe rri/ni��a/requiremenls of 1Yfinn._Stat;§ 115.55(2001)and Minnesota R. ch. 70t40,(1999�_ Please refer <br /> to local ordinances for other requirements or informatfon especially for.compliance recjuirements.for bedroom addl'tlons <br /> � <br /> Gen�ra6^ , i <br /> - - ' <br /> �ate of7fr��p�c�ion� _I���oS IReasoa� forinspectlono �v��Q�1��� <br /> 'P�`�'yr1 ti� <br /> �ropertyr Own�r(s) �0�1�, � '�A�-1L.l� O'f� � <br /> � . T��epf�one (�.y��.)�.4� - �4lpC�c� <br /> �'e�-smt� reques�in� 6n�per.tio�u _ ��W1�=- <br /> � 'i'�9ephone ( ) <br /> ��t��aas-�ss . ac�� � �v����� -�,.�,����. ______-_-- ctty�^cz��� � <br /> Zi� cmd� <br /> Fire V�o./ I�arce@ �da. � �i • �oditi�r.N�t�.4'�-"�'t�� <br /> i "fovvtas8i i p <br /> Legal De�crip�ioti . <br /> ILocal Regulatoty�uttnority G��-( ��- b���, . �� � , � <br /> 1Dage sys�etn cottstcucte�9_Q°�tt?'�=i� 1"?'`"�(� ,systetn Bn�horeland�,re�: yes!� 5ysten� i�a W�lllheac9 <br /> P'rotectian ,At-e�: yes(`rio Syst�m seaying�a �I��H ficer�s��1 faciiity: yes -no_ �oca8 F�errralt# (s'f any) <br /> � <br /> Systems built prior.to April I, 1996 �nci no�foc,�ted fn Systems�located in Shoreland;or Wellhead.Protection <br /> Shoreland or Wellhead Protectlon�Area or Setving a Food, <br /> Beverage or Lodging Esfiablisf�ment . Areas a�•SerVing.a Food;Eeverage.or Lodging <br /> , Estab►ishment, �e systems Quiit�gt�s- <br /> . = Mareh 31 1996 <br /> Is tP�e s�slem a� imtt�inent threa� �in ne�F�s�C�1e��lth o • Ts t e.� tem an ;enm�nee�t the-eat to �iublic heaitFe <br /> sa�e ? (a yes answer is an I7PHS system).�. —� —�-�5 <br /> �°�'��f��� (a�yes answer is an ITPH.S system) � � <br /> - Discharge of sewage to the ground surfac�? YES �� - D(scharge of sewage to th�ground surface? YES ,NO <br /> - D(sct�arge oP sewage to dralritf(e or surface waters7 YE5 -Discha�'ge of sewage to dtaintlle or surface waters?YES NO <br /> -Sewage backu�Into dwellfng? � � , <br /> -YFS ➢ -Sewage.backup Into civirelling7 �YES NO <br /> -Situatfon w(th the polentfal to immediately and � <br /> -.�Ilua.tfon wltt�the potentfal to immedlately and <br /> adversely fmpact or threaten publlc health or � • ' � <br /> safe 7 � 'adversely Impact or thPeate� publlc health or <br /> ty� • � YE_S �) . safety7 . <br /> ; YES NO <br /> Is�he sv5tem failin4a (a yesansweri�.a fai/i�gsystem) Ts f:he s�r�tenn`-failiQie�� (a yes.answePisa fai/ingsystem) <br /> - Less thah TWo feet of verUcal.separation betw�en . -Less than 7F�f8EE feet of vertical separatfon.betvVeen <br /> syst�m L�ottonr and 5aturated soil or�[iedrocic? ES NO -systerp bottom arid�atur.ated soil or bedrodc? YES NO <br /> -A seepage plt, cesspool,drywell,orleaching pft? YC.S NO <br /> , , � <br /> . -A seepage pil,cesspool, drywell, or leachfng pit7 YE5 NO <br /> Is th�su�t�m non-com[�IiaiL � � •" • <br /> - Is the sysfem regufated under a moi�iitoring plan or • � z� B�e systerr��t�on-coQngliant? . <br /> operating permit? (if no . o to a e 2 - �s the systi�rra�regulated under a .monitorin.g plan or <br /> � g p �. � YES Vp � operating permit7 (if no,yo to paga�2) ' YES NO <br /> lf yes, � . <br /> - Has the required monitoring talcen pPace7 YE.� NO �fyes, . - <br /> (!f no, rhe system Is non-com I !n � � -Has the required monitoring taken plare? � YES No <br /> . , py •g� (Ifno, fhe�syst�m Is non-cei'rn l ln . <br /> '' PY 9) <br /> - Doeslhe monitoring indicate.that tho systerri meets -� � - <br /> � -:: <br /> ... ; . - �=Does:the.monitoting fndicate�thaf the system meets <br /> perfo"rrnance expectations? � - � � � YE�' N � <br /> � ..... :, , . � �.. , .... .�, ��: � O .. : : p � . <br /> : ..� . , . .. ..... : ., �e co ei�pectatio.�is? <br /> (If no, itfe:sysfem is non-com ! in ' . . �°rman YES NO <br /> .. � � . ,-... <br /> � . . . AY 9) . �, • • (If no, ihe s �tem is non-com 1 In ' .. . � . � <br /> � yr P Y 9� <br /> � <br /> `„ i ._ . . . • . -- � . . <br /> ' Page 1 of 2 . • wq-wwists4.31 . <br /> � . <br /> � - . • . . <br />