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05� 14:20 9528733112 PAGE 04/09 Parcel number: _ � Systern status: Compliant ❑ Noncompliant � ` (as determined y f is form) Hydraulic Perfarn�ance and Other Compliance Compliance Issue ##1 f ' Date of observ�tion: � � Reason for observation: `� This fo�m expires upon next inspection or in three years, whichever occurs first: Complian�e questfons/c�iteria: (Requlred) Verfficatlon Method*: (Optional) (Ch�ck the appropriate box) (Check the appropriate boxJ Does the system discharge sewage to thQ ❑Yes �No �Searched for surface outlet yround surface? �-,J� � PerFvrmed hydraulic test D�es the system discharge sewage to draln [� Yes �xNo _tif�or surtece waters? � � �Searched for seeping in yard Does the system cause sewage backup ❑ Yes No ❑ Checked for backup in home into dwellin or establishment? ❑ E�ccessive ponding in soil syst�m/p-boxes Do other situations exist that have the ❑Yes No potential to immediately and adversely ❑ Homeowner testimony impact o�threaten public health or safety �Examined For surging in tank etectncal, unsafe covers,etc.)? » �^"""'' � "Black soil"above soil dispersal system Any"yes"answerindlcafes fhat the system!s an imminent threat to�ublic hea/th and safety. ❑ System requires"emergency'pumping "' ❑ Perfortned dye test Does the system pose a threat to ground [� Yes No �� water for any conditions deemed nan- ❑ Other: ,_.t�l� /o Y1�_._�.�.. ��2�.. rotective as determined b the ins ector? IL?��_f,� � �! �Q_.�Oa y� �� . . "Yes"indicafes fhat the sysfem!s falling te pratect _ ,t �' _ ground wafer. If"yes'; deswTbe the conditivn noted: ---' " *No standard protoco!exists. This list is not oxhausfrve. -- --• in sequentiaJ order, nor does ii indicate which combinatlons ere necessary to make fhis defermrnarion. Certification This form is to be compteted and attached to the Summary Form of the Minnesota Pollution Control A�ency's(MPCA)Compliance I�spectio� Form fio�Exlsting Subsurface Sewage Treatment Systems. Observations, interpretations, and conclusions must be completed by an inspector. Completed form must be submitted to the local unit of government withln 15 days. Property owner name(s); _� (r , � _ __+___! Property address' G7��— �� ` ----. . _-----. Property owner's address(if different)= County: _��u v� 1��'�i�l�-- Phone: __ ._�._... ...--------- � !hereby certify that�personally made the observafions, rnterprefations, end conclusions reported on this form and fhat they are r,orrect, Name: _��_ __ O _ Certifioation number: ��D�-I -- ---••-_�....-.-•.-•---- 6us�ness license name and number: Cj�� ,�2,(�U�..(QS �'l1L_ ��j'_Q� __,__________, or Name of loCal unit o orn t: S�gnature; . _, _,_ � Date: , � — (�._.._.....—...�_. .. wq•wwists4-31 Complio�ce Inspection Form for Existing SSTS 4/1/08