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Parcei number. 27-11&-23-3'I-0021 System status: � Comp[iant ❑ Nancompliant <br /> � (as determined by this farm) <br /> HydrauEic Perforrs�ance a�ed t�her Compiiance - Com�aliance /nspectian Farm for Existir�g SSTS <br /> Compliance lssue #1 of 4 <br /> Date of observation: 7-21-11 Reason for observation: 7ransfer ofi title <br /> This form expires upon next inspection ar in three years,whichever occurs fir5: 7-2i-'f4 <br /> CQmpfiance q�restions/criteria: (Required) Verification Method*: (optiona� <br /> (Check the appropriafe boxJ <br /> —�-- (Check the apprapriate box) <br /> �oes the system discharge sewage to the ❑Yes � No <br /> �ound surFace? , [ Searched for surface outlet <br /> Does the system discharge sewage to drain j ❑Yes � No ❑ Performed hydraulic test <br /> tile or surFace waters? i � Searched for seeping in yard <br /> Does the sysfem cause se�vage backup � ❑Yes � No ❑ Checked for backup in home <br /> into c�f!ing or establishment? � <br /> ❑ F�ccessive ponding in soil systemraboxes <br /> Do other situafions exist that h2ve the ❑ Yes � No <br /> potential to immediately and adversely ❑ Homeowner tesfimony <br /> impact or threaten pub!ic health or safety ❑ Examined for surging in tank <br /> (eieatrical, unsafe covers, eta ? � � °Black soilA above soil dispersal system <br /> Ar,y"yes"answer indicafes that the system is an imminerrt <br /> threaf b�ublic health and safefy. ❑ System requires°emergenc�'pum in <br /> � s <br /> ❑ PerFormed dye test <br /> Does the systsm pose a threat to gcound �' ❑Yes � f�o � Ottier. <br /> water far any condiUons deemed non- <br /> protective 2s cietermined by the inspector? j <br /> "Yes"irrdecates that fhe system is fai/ing to prafect <br /> ground water_tf`yes", describe�fie cond'rtion rtoted: <br /> `No starto`ard protoco!exists. This l�st is not exhaustive, <br /> in sequen�ra/order,nor does it indfcate which <br /> combinafions are necessary to make this determinafron. <br /> Certification <br /> This form is to f.�e completed and attached to tha Summary Fortn of the Minnesofa Pollution Control Agenc�s (MPCA)CoenpiFance <br /> irs�pecfiion Form for Existing Su�surface Sewage Treatment Systems.Observabons,interpretations, and conclusions must be <br /> completed by an inspector. Completed farm must be submitted to fhe locaf uni�of govemmsnt w�thin 15 days. <br /> Property owner name(s): <br /> Property address: 1120 Cox Farm Road, Orono MN 55356 <br /> Proper#y owners address(if differertt): <br /> Gaur.ty: Henne�in __ Property owner phone: <br /> 1 her�by certify that i personally macie.he observations, irrterpr�tations, and conclusions 2por�ed on this form aRd thzt fhey are <br /> cor,�ct <br /> Name: Pemei Hentges Certification number. 2464 <br /> Business ficense name umber. Chip's Septic Serv'sce LLC or <br /> Name of{ocal unit of�vemmen`: <br /> \ <br /> Sign2ture: _ Dafe: 7-21-11 <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-38b4 • TlY 651-282-533Z or 800-657-3864 • Avai:able in attemative formas <br /> wq-wwrsts4-31 • 4/14109 <br />