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. � � Compliance Inspection Form for Existing Individual Sewage Treatment Systems � This form reflects the requirements of the 1996 version of MN Rules Chapter 7080 Minnesota Pollution Control Agency Note:Local inspection standards may be more or less restrictive than the state requirements. These differences must be made available by the Local Unit of Government. Date of Inspection: �'�' Property Owner(s) Telephone( )� Person requesting inspection(if different than owner) Telephone ( ) Reason for inspection: , , .-� Site Address City , Zip Code Unit of Government Regulating this property Fire No. Parcel No. Township Name Township Rangc Section Quarter (Check appropriate sewer system component and indicate location on site sketch). Tank s : Soii Treatment System: Other(briefly describe�: Flow Meter �-Septic tank Rock trench _Alternative system _Aerobic tank _Gravelless pipe trench _�xperimental system Yes No ,�Pump tank _Chamber trench _Warrantied system If yes, Holding tank Seepage bed Exp. Date: Other �`,�. Mound Other _At-grade Svstem Classification System Built Prior to April 1, 1996 and not Located in Any System located in Shoreland or Wellhead Shoreland or Wellhead Protection Area or Serving a Protection Area or Serving a Food, Beverage or Food, Beverage or Lodging Establishment Lodging Establishment, plus all systems Built after April l, 1996 Is the sxstem an imminent Qublic health threat(IPHT,L Up_grade Is the system an IPHT? Upgrade 1.Discharge of sewage to the ground surface? YES NO 10 mo 1.Discharge of sewage to the ground surface? YES NO 10 mo 2.Dischazge of sewage to draintile 2.Discharge of sewage to draintile or or surface waters? YES NO 10 mo surface waters? YES; ,I�IO.,10 mo 3.Sewage backup into dwelling? YES NO 10 mo 3.Sewage backup into dwelling? YES�TrO:'10 mo 4.Situation with the potential to immediately and 4.Situation with the potential immediately and ^`� adversely impact or threaten public health or adversely impact or threaten public health or s--�� safety? YES NO ]0 mo safety? YES(`NO ?0 mo Is the svstem failing? Is the system failing? `" 5.Less than TWO feet of vertical separation between 5.Less than THREE feet of vertical separation between , system bottom and saturated soil or bedrock? YES NO LGU** system bottom and saturated soil or bedrock? YES� NQ,,LGU** 6.A seepage pit,cesspool,drywell,or leaching pit? YES NO LGU** 6.A seepage pit, cesspool,drywell,or leaching pit?YES; NO LGU** ** LGU=Local Unit of Government ordinance must specify the time period within which the system must be upgraded. STATUS OF THE SYSTEM Based on the compliance criteria above the system status is (check one)�'in compliance(functioning)�failing�an imminent threat therefore,this document is a(check one)�3"Certificate of Compliance ❑No[ice of Noncompliance. Page 1 of 2