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Apr 22 10 11:59a 763-213-0695 p.3 <br /> /� � � c�R��l> <br /> Parcel number: ,� ��� C����/1}Yy`S;Gt! ,�'', w-2�f"_SysSern status: �Compliant ❑Noncompiiant <br /> (as deterrnined by this foim) <br /> Hydrau�ic Perfarmance and Other Compliance <br /> Compliance Issue #1 of 4 , <br /> Date of obser�ation: �— v2 �— �(� Reason For observation: ' <br /> This form expires upon next inspection or in three years, whichever occurs first: <br /> Corr�pliance questiortslc�iteria: (Required) Yerification Method*: (Optional) <br /> (Check tne a�priate box) (Check the approprrate box) <br /> �oes the system discharge sewage to the ❑ Yes � No � Searched for surFace ouUet <br /> �round surface? , <br /> Does the system discharge sewage to drain � ❑ Performed hydraulic test <br /> ❑Yes � No <br /> ti e or surface waters? [$ Searched for seeping in yard <br /> Coes the sysiem cause sewage backup ❑Yes � No � Checked for backup in home <br /> irto dwellin or establishment? <br /> ❑ Excessive ponding in soil system/D-boxes <br /> Do other situations exist that have 1he ❑Yes (� No [� Horneowner testimony <br /> poten:ial to immediately and adversely <br /> impact or ihreaten pubiic health or safety � � Examined for surging in tank <br /> (elecirical, unsafe covers, etc.)? [J�J 'Black soil' above soil dispersal system <br /> Any"yes"answer indicates ihat the system is an imminent <br /> ihreat to pubJic health and safeiy. ❑ System requires"emergency"pumping <br /> ❑ Performed dye test <br /> Does the sysiem pose a threat lo ground Q Yes No �C�� <br /> water for any conditions deemed non- � � Other; ^ �p ui»+r <br /> protecti�e as determined by the inspector? t7( _ °�j r, jp <br /> "Yes"indicafes fhat the system is failing to protect <br /> g�ound water.lf'yes'; describe fhe condifion�oted: <br /> 'No standard protvco!exists. This lis�is not exhaustive, <br /> in sequenfia!order, nor does rt indreate which <br /> combinatrons are necessary to make ihis defermination. <br /> Certificatior� <br /> This form is to be completed and attacheci to the Summary Form of the Minnesota Pollution Control Agency's(MPCA) Compliance <br /> Inspection Form far Existing Subsurface Sewage Treatment Systems.Observations, interpretatio�s, and conclusions musi be <br /> completed by ar �nspector. Completed form musl be submitted to the local unit of government within'15 days. <br /> Property owner name(s)� 'G� � <br /> Property address: 01 77� Gc>wnfr�-�dt .���'. �L�,S f • <br /> Pr�perty owner's address(it diiferent): � <br /> ( ✓1�. W�rk , <br /> County: _��iY�NL. Phone: -��'S,�—�U��D ZL�_____��,f'-��3��—�%,�� <br /> !hereby cerirfy that/personally made fhe observations, ;nferpretations, and conc/usions reported on this form and that theyare <br /> correct. <br /> Name: dh �.�"' Certification �umber � � �� <br /> Business license name and nurnber; �`���� �11� Le,s'6�JL'D � -�/�L • 3 7� __. or <br /> Name of;ocal unit of government: <br /> Signature: �1��� . Dafe: � � �I� <br /> wq-wwists4-31 Comp�rance lnspection Form for Fxrsting 5ST5 <br /> 411/08 ' <br />