septic info - Laserfiche WebLink

Home Browse Search

2/25/02 Water/Wastewater-ISTS9.31 .�'"w!: � Compliance Inspection Form for Existing : 'i _ _ Individual Sewage Treatment Systems Minnesota Pollution .�,�.� Control Agency Completion of Ihis form fulfills the minimal requirements of Minn. Stat. § 115.55(2001)and Minnesota R. ch. 7080(1999). Please refer to local ordinances for other requirements or information, especially for compliance requirements for bedroom additions. General: Date of Inspection: � o d Reason for inspection: S'9"!� Property Owner(s) Telephone ( ) Person requesting inspection Tel�phone ( ) Site Address � 7.�J� ��'�� -�y� lJt, � City ��L��r� Zip Code Fire No./ Parcel No. County l�£�vw..s�� Township Legal Description Local Regulatory Authority � � �-f Date system constructed f�� g-�5 System in Shoreland Area: yes t� System in Wellhead Protection Area: yes ((� System serving a MDH licensed facility: yes �Local Permit# (if any) Systems built prior to April 1, 1996 and not located in Systems located in Shoreland or Wellhead Protection Shoreland or Wellhead Protection Area or Serving a Food, Areas or Serving a Food, Beverage or Lodging Beverage or Lodging Establishment Establishment, or systems Built after- March 31 1996 �:.� Is the sYstem an imminent threat to public health or Is the system an imminent threat to public health . safe ? (a yes answer is an ITPHS system) or safetv? (a yes answer is an ITPHS system) - Discharge of sewage to the ground surface? YES -Discharge of sewage to the ground surface? YES NO - Discharge of sewage to draintile or surface waters? YES � -Discharge of sewage to draintile or surface waters?YES NO - Sewage backup into dwelling? YES � -Sewage backup into dwelling? YES NO - Situation with the potential to immediately and -Situation with the potential to immediately and adversely impact or threaten public health or adversely impact or threaten public health or safery? YES � safety? YES NO Is the system failin4? (a yes answer is a failing system) I�the system failinn? (a yes answer is a failing system) - Less than TVVO feet of vertical separation between -Less than THREE feet of vertical separation between system bottom and saturated soil or bedrock? YES � system bottom and saturated soil or bedrock? YES NO -A seepage pit, cesspool, drywell, or teaching pit? YES � -A seepage pit, cesspool,drywell, or leaching pit? YES NO Is the system non-compliant? Is the system non-compliant? - Is the system regulated under a monitoring plan or - Is the system regulated under a monitoring plan or operating permit? (if no, go to page 2J YES � operating permit? (if no, go to page 2) YES NO If yes, If yes, - Has the required monitoring taken place? YES NO - Has the required monitoring taken place? YES NO (If no, the system is non-complying) (If no, Ihe system is non-complying) - Does the monitoring indicate that the system meets -Does the monitoring indicate that the system meets performance expectations? YES NO performance expectations? YES NO (If no, the system is non-complying) (If no, the system is non-c�mplying) ..fk..S �i`..�.! Page 1 of 2 wq-wwists4.31