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, 11/1612611 02:31 7634975011 SPTESTINGINC PAGE 04109 <br /> Parcel number: ___ System status: � Compliant ❑Noncompllant <br /> (�s determined by this 1`orm) <br /> Hyd�aullc ��rfor�mance 2�nd Oth�r ComplOar�ce — Compliance /nspection Form forExisting SSTS <br /> Compliance Issue #1 of 4 <br /> Date of observation: _,1� - I`��'ap�.� ,� Reason for obsen►ation; ��r(.� .��� <br /> This form expires upon next Inspection or in three years,whichevar ocours frrst: � <br /> — "�"'--^--�� <br /> Compliar�ce questiflns/criteria: (Required) VerOficatlon� Metihod;: (optional) <br /> (Cl7eck th� ro riate box (Ch@ck Che approprlato 6ax) <br /> Does the system dlscharge sewage to the ❑Yes � No <br /> ._ground surface? � Searched for surFace outlet No <br /> boes the system discharge sewage to drain 0 Yes ❑ No Q Pe�°�ed hydreulic test <br /> tile or sutface waters? � Searched for seeping in yard IJo <br /> Does the system cause sewage backUp ❑Yes � No � Checked for backup in home <br /> into dwelling or establfshment9 <br /> �� - � Excessfve ponding In soil system/D-boxes �.1p <br /> Do other situations exist that have the ❑Yes � No <br /> potentlal to immedlateqy and advers�ly 0 Hom�owner testimony <br /> impect or threaten public health or s2f�ty ❑ Examined for surging in kank <br /> _,(electrlcal,unsafie cavers, etc. ? <br /> Any"yes"answ�r Indlcates that me system is an lmmfnent � "Black soil"ebove soil dlspersal sysiem tJ�o <br /> tHrc,�!to pub/Ic hea/th and saf�ty. ❑ System requires"emergency"pumping <br /> " �] Perfarmed dye test <br /> Does the system pose a threat to ground ❑Yes �No <br /> water for any conditions deemed non- ❑ Other: <br /> __prote�tive as determined by the inspector? , � �"— <br /> "Yes"indlcates that the syst�am is fallfng to pro#ect " <br /> ground water.If"yes'; describe the cortditfon r►olpd: ""' --- <br /> 'No sfand�id pro(nco/ezists. tl�Is!!s#is nof exhausfive, <br /> � A���� � �V-�'���—�•��`' in sequentia!orde� nor does ii indlcate which <br /> �1rJ a��4����,/L_,��1�✓�, _ comb;nafions are necessery ta make thls determinatlon. <br /> Certificatiora <br /> This fiorm is to be completed and attacNed to the Summ�ry Form ofi the Minnesota Pollution Control Agency's (MPCA)Compliance <br /> Inspectlon Fnrm for Existing SubsurFac�Sewage Treatmen#Sy9tems.Observations, interpretations, and conclusions must be <br /> completed by an inspector, Compl�ted fo�m must be submitted to tt�e local unit of government withln 15 days. <br /> Property owner name(s): 'O��L�_g���i _�p�t�ryp� <br /> Wroperty address: �b 9��' r'.,.n..�� ,5�4��,, I�l1�J�-iZc�J�L • ..... , .� <br /> Property owner's addr�ess(if dltiprent): <br /> County: .�� •�� <br /> . �'����� ,_. Property�owner phone: �(mJ'7� " �1op M_ 107 (a� ^� <br /> !hereby certr�y thaf 1 p�ersonally made t1�e observat/ons, interpretaP/ens,and concluslons reported on thls form and fh�t they a►'e <br /> correcr. <br /> Name: S�(�_y�1, '�3_�,�5_LV-ti��4�i��;,z.._. _,� Certification number: lo�� T <br /> Business license name and num'ber. S=Q ^�t%its'���,,�f� 1�L` . '�.��C.,_°���'�-� ���^��_�3,5 a� or M <br /> Name o4 locel nit of government: <br /> Slgnature: :i`��--:�� _..-.�.—� .. �.,.. Datm: /�p�oZ —�01,1 _ . <br /> WWW.pCd.5tdt2.fT111.U5 � 651-296-63(I� . Ann-b57-�RFid ■ TTV�,�.1.9C7.r.z��.�.onn_scv.�e�� _ ..._:�_��_:._ _�.._.. ..� . � <br />