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Parcel number: System status: j�,Compliant ❑Noncompliant <br /> (as determined x�y��is iorm) <br /> ����a��ic ����s�e����� �r�� ����� ���s�����c� <br /> ti.�PYl��i��iC� I55U� ;=` �; <br /> Date of observation: « Z y�'p Reason for observation: .r/�- l� , <br /> This forir e;:pires upon nexi inspection or in�ree years,whichever occurs Tirst: f//,L Si /L <br /> —�—�7 <br /> i.ompiiance quesiions/criteria: (Required) VEri�ication ivietlaod�: (Optinnal) <br /> (Check the a ro riate box) (Check fhe appi�opriate box) <br /> Does the system discharge sev✓age to the I ❑Yes No <br /> round surface? �Searched for surface outlet <br /> �/ ❑ Performed hydraulic test <br /> Does the system discnarge se�nfage�o drain ❑Yes ��iVo <br /> �ile or surFace�+�aters? I �Searched for seeping in yard <br /> Does the s�stem cause se�,vage backup f ❑Yes �lo ❑ Checked for backup in home <br /> into da�relling or establishmeni? i <br /> ❑ E��cessive ponding in soii system/D-boxes <br /> Do other sifuations exist that have�he I ❑Yes �o � Homeoviner testimony <br /> potential to immediately and adversely <br /> impact or threaten public health or safety � ❑ Examined for surging in tank <br /> (electri�l,unsaie covers, etc.)? � � "Black soil"above soil dispersal system <br /> Any`:�es"ansyver+ndicafes ft�ai;i�e s,�st2;-�is; °%�r-,ni,:er;. <br /> fhreaf fo public i�ealih and safefy. ❑ Sysfem requires"emergency"pumping <br /> � ❑ Performed dye tes2 <br /> Does tne system pose a threat to g;ound I ❑Y'es iti�o � Other: <br /> yvaier for any conditions deemed non- ' <br /> protactive as determined by the inspector? ; <br /> "Yes"indicates rhat tne system is;ailing to protect <br /> grcur.c!v�ater.,'f"�ies",d�scribe the ccnc(it,"or. rtote�: <br /> "No sfandard profocol e:<ists. This list+s nof exhaustive, <br /> - - ----- - - --- ---- rn secruentra(order. nor does if indicate which <br /> combinations are necessary to make fl�is de(erminafion. <br /> ���'�3�3 Lc�l��; <br /> This form is to be compleied and attached to the Summar;�Form or the Niinnesota Polluiion Control Hgency's(P11PCH)Cempiia�ce <br /> fnspection �orm for Existiny Subsu�iace SeWrage Trea�ment Systems. Observations, interpretaiions,and conclusions must be <br /> completed by an inspector_ Completed form must be submitted to the local unit or government within 15 days. <br /> Property owner name(sl <br /> Properf address: � ��� C` p v.v r�,� �`� _ �� <br /> Property owner s address(if differentj: <br /> County: ��y,v Phone: <br /> I hereby certify rhar 1,Qersonally made the obsen�aiions, interpretafrons, and conclusions reported on this form and fhat they are <br /> correct. <br /> Name: �D I�L,�W /t 6"��✓at/ Certification nuinber: ��(O <br /> Business license name and number. �j � �La � ���,7� ��� ar <br /> iVame oi lo u oi aovemment: �/�/T� <br /> Signature: Date: /� ,2. �/ (�� <br /> wq-wwists�-31 Compltance lnspection Form for Existing SSTS <br /> =�/1/08 <br />