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Parcel number: System status: (�Compliant ❑Noncompliant (as determined by this form) Hydraulic Performance and Other Compliance Compliance Issue #1 of 4 Date of observation: Reason for observation: SZ �� This form expires upon next inspection or in three years,whichever occurs first: Compliance questions/criteria: (Required) Verification Method*:(Optional) Check the a ro riate box (Check the appropriate box) Does the system discharge sewage to the ❑Yes No round surFace? � Searched for surface ouUet � ❑ Performed hydraulic test Does the system discharge sewage to drain ❑Yes No file or surface waters? �Searched for seeping in yard Does the system cause sewage backup ❑Yes �No ❑ Checked for backup in home irrto dw�elling or eslablishmenY? [] ��ve ponding in soil system/D-boxes Do other situations exist that have the ❑Yes �No � Homeowner testimony potential to immediately and adversely impact or threaten public health or safety ❑ Examined for surging in tank electrical,unsafe covers,etc. ? ❑ "Black soil"above soil dispersal system Any"y�es'°answer indlcates that fhe system is an imm/nenf threat to publlc health and safety. ❑ System requires"emergency°pumping ❑ Performed dye test Does the system pose a threat to ground ❑Yes [�No wafier for any conditions deemed non- ❑ Other: rotective as determined 6y the ins ector'l "Yes"lndlcates that fhe system is failing to protect ground water.If"yes",describe the condition noted: "No standard protocol exists. This list is not exhausfive, in sequential order,nor does it indicate which combinations are necessary fo make this deferminafion. Certification This form is to be completed and atlached to the Summary Form ofthe Minnesota Pollu6on Control P�qency's(MPCA)Compllance Inspection Form for Existlng Subsurface Sewage Treatment 3ysbems.Observafions, interpretations,and conclusions must be completed by an inspector.Completed form must be submitted to the local unit of govemment within 15 days. Property owner name(s): Property address: �7�� '- ( lL �' C,� �L��J c)�✓� �-�L Property owner's address(�f different): County: 1 � ;� �v,�t1� ,� Phone: / l here6y ce�tify that I personaHy made fhe obseivafions,interpretaSons,and conclusions iaported on fhis form snd fhat they sre correct. �lame� ��jV � ��L,-T� Certification number: � �,�� ;� : _.. , 1 -- -- -+—� ---- . . � t ir,=:.:i�; Ir..�i� �lil;:'.�:I�: y'YV '�' __�A,r� ._�/�l, y �... ./ Ni�nr �_�iLal� C'-�'' •!'-_ 't� ___- i - ^ ._ _ � _.__._ ___ ._ __-_ . . . .. . . , . , . ._ 1 F- l/ /C��/Q , __-__. _.__ Signaiure: (�-v, Date: ��i L wq-wwists4-31 Comp(iance lnspection Form for Existing 5573 4/1/08