Laserfiche WebLink
03/14/2009 01: 21 7634975e11 SPTE�7INGINC PAGE 04/09 <br /> Parcel number� , .,,., Sys�em status: � Com liant <br /> P ❑ Noncompllant <br /> (as dof�rm�nod by this form) <br /> R�ydr��alic Peof�nr�na ce ��d Othek Comp�panc� <br /> Cc►mpliance Issue #1 f 4 <br /> Dete of observation: __3 ' =[�_ � I�oeson for obsery�tion: <br /> ����._'(�5�-� <br /> This form expires upon next i spectlon o�in three yoa�s,whiGhever occurs(irst: � <br /> C�omptbance ques#Aons/cr teria: (Requlred) Verification MethocE": (Optional) � <br /> _ Checic tl�a t�pproprial�e b xl . <br /> Does th�system disclia�ge s wage to the ❑Yes � (Ch�ecic tho appropriate boxJ <br /> _ground surface? � NO � Searched for surfece outlot <br /> Does the system disclier�e s wage to draln I]Yes C] Nu Q �orformed hydraulic test <br /> tile or surFace waters? _ _ � Searched far seeping in yard 1�1c� <br /> Does ihe�ystom causo sewa e bacicup � []Yes �J Nn. ❑ Checked for backup In home <br /> _Into dwelling or,establishment <br /> ' � Excessive ponding in soil system/D-boxes y� <br /> Do other situ�tlons exlst th�t aue the �Yes (j� N� <br /> potential to immedlately and a versely C� f-lomeowner testimony <br /> impact or threaten public heal h or sefeiy ❑ Ex�mined for surgin�in tank <br /> (electrlcal,_unsafe covers�etc. 7 <br /> Any"yas"an5wcrindicAtes t at fhe sys��e�n is an Irriminont � "�I�ck soil"ebovo soll disparsal 9ystam �p <br /> ilrreat ta public hoa!!h Andsa ety. ❑ Syslem roqulres"emefgency"pu,nping <br /> Does tho system pose a threat to ground ❑Yes � Performed dye test <br /> � Na <br /> w�ter for any conditions de�m d non- I� Other; <br /> � rotective as det�rmined_ by th ins ep clor?,� ' " — <br /> "Yas"indfcates thet the sys m is failing ta protecr �� � a <br /> �round water. If��yes", desc ibe t�he crnnditfon noRed: � ���� - .� . „ <br /> _, _„ *No standard protocol exlsts. This/isP!s not exhaustive, <br /> "- „' �� - in sequontial order,nor does it lndicate whicl� <br /> — - -"' - - -,-.— -, . „ . combinatlons are necosvr�ry(n maJre lhis delerminstion, <br /> C�rtification <br /> 1'his form is to be complet�d a d attached to the Summary Form of the Minneso�a Pollution Control Agency's (MPCA) Compllan�e <br /> Inspec#6en Form for Existln SubsurFace SeHrege Treatmenx 3ystems. Obse:rvaQons, interpretations,and conclusians must be <br /> complet�d by an inapector, Co pleted form must be submltted to the lacal unit mf government within 15 days. <br /> Property owner name(s); �� <br /> �.,_ 1N��_..S t�L'S , w` <br /> I�roperty address; _, �!({,,v _,G��Yk� .• '� '—' ` <br /> - — -- ��b.�—D_�o�c?_ <br /> Property owner's add�ess (iFdl renl)� � `—"— <br /> County; _ _ , _ Phone: <br /> . ... .. ..��.,— <br /> 1 hereby cert)fy thaf I personall made fhe obsmrvaffons, infBipr�tations, snd conc/usions roporPed on thls form�ncJ thaf they�r� <br /> correct. <br /> N�mo: ���►}%���; �<,'�0,�_�yy���S_ CertPfic:ation number: Fs' 7 <br /> �—__... <br /> Business I(cense natne and nu ber; �- ���'i'�_-����_� �� n};.�� -�� �— <br /> - --�-�- ���l0 3�'��L- 3..��(�r oR ... <br /> Name of local unit o�F governm ht: <br /> Slgnature: --.,,_ . ,. . .... .,_ _ , , _ <br /> —•. _.., ._ . ,. . _,. Date� <br /> wq-wwisrs4•31 C.ampliance Inspection Form�or Existln�SSTS <br /> 4/1/08 <br />