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Parcei numbzr. 27-118-23-31-Ofl21 _ System status: �Compliant ❑ Noncompiiant <br /> --__. <br /> • {as de#ermined 6y this form) <br /> TanK lntegrify and Safety Compiia�sce - Compfiance lnspeclion Form forExis6ng SSTS <br /> Co�ptiance Issue #2 of 4 <br /> Date of observatian: 7-2�-11 Reason for observation: transfer of titie <br /> This form expires on (three years}: 7-21-14 <br /> Comptiance questions/criferia: (Required} Verification Methad`*: (Optional) <br /> (Check the apprnpriate box} (Check the a <br /> ppmpriate box) <br /> Does the system cansist of a seepage pit*, ; ❑Yes � No <br /> cesspool,�eil,or leaching pit? ' � Probed tank bottom <br /> �o any sewage tank(s)leak below their ❑Yes � No � Observed low{iquid{evel <br /> designed aperating depth? � � Examined construction rscords <br /> ff yes, identify v,rhich ❑ Examined empty(purrzpec�fank <br /> sewage tank{eaks. ❑ Probed outside tank for"black soil° <br /> Any yes"anstnrerindicates that the system is failing to protect <br /> ground water_ ❑ Pressure/vacuum check <br /> ❑ Other. <br /> ` Seepage pits mesting 708Q.2550 may be compfiant if ailowed — <br /> in ordinance hy local permitting authority. <br /> `No standarrf prvtocol exists. Tl�is lisf is not e�d�taustive,in <br /> sequerrfia!order,nor does it indicafe which combinafions <br /> are necessary to make fhis determirra±ron. <br /> Safety Cf�eck <br /> �. ,4r�maintena��hole covers damaged,cracked,or appeared to be structuralfy ur.sound? ❑Yes* � No <br /> 2_ Were maintenat�ce hole covers replaced in a secur�d manner(e.g.,screws repfaced)? �Yes ❑ Na* <br /> 3. Was secondary acc�ss resfraint presen;(safety pan,second cover,o�safety netting)-highly recommended. ❑Yes �J No <br /> 4. Ace other safetylhealfn issue present? y�� <br /> ❑ � No <br /> cxplairr <br /> 'System is an irrrmFrrer�f ff�rreat to public heafth and safety. <br /> C�rtiftcatfon <br /> This form is to bs carrepleted and attached to the Summary Form of the Minneso#a Po�lution Contro{Agenc�s(MPCA)Complianee <br /> !nspectian Form far Existing Subsurface Sewage Treatment Systems,Observations, interpretations, and conclusions musf be <br /> completed by an inspector, maintainer; or service provider. Completed form musi be submitted to the locsl unit of govemment within <br /> 15 days. <br /> Property owner nans{s): <br /> Rroperty address: 1120 Cox�arm Road, Orono MN 55358 <br /> Property owne�s address(�f d�fferent): ' <br /> Couniy: Hennepin Prope�ty owner phone: <br /> I hereby certify that!p�rsorral/y made the observations,in2erp�fations, and conclusions reported on this forrrr and that they ar� <br /> correct <br /> Name: Pemel Hentges Certifcation number. 2064 <br /> Business liceRse nam and n r. Chip's Septic Service LLC or <br /> Name of locai unit of go emmen#: '�-� <br /> � — -_ ._ - <br /> Signature: �---�'� Qate: 7-21-11 <br /> www.pca.state.ma.us - 651-29b-6�Q0 - 800-6�7-3864 • 1TY 651-282-5332 or 800•b57-3864 • Available in a[ternative formats <br /> wq-wwists4-3f - 4/24/Q9 <br />