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_,_..,.._ ....._., .---._.....�. _...�..�. , Compliance Inspection Form for Existing � Individual Sewage Treatment Systems Minnesota Pollution `i Co�trot Agency Completion of this form fulti►Is the minimal requirements of Minn. Stai. § 115.55(2001)and Minnesota R. ch. 7080(1999). Please refer 10 local ordinences for other requiremenis or information, especially for compliance requirements for bedroom addi2ions. General: Date of Inspection: / � � Reason for inspection: _��r��G� 1 Property owner(s)_,�� l�C;t►'1 'Telephone (Y�';z) 7��— �7C�� Person requesting inspection GiYYIe.�. Telephone ( ) Site Address �c '(� ' V �i I City d �O!''�d Zip Code � 3S�(p Fire No./ Parcel No. County ��/•"`"� Township Legal Description Local Regulatory Authority _ _ C_��4 Date system constructed .� System in Shoreland Area: yes� System in Wellhead Protection Area: yes �stem serving a MDH licensed facility: yes �lvcal Permit # (if any) Systems built prior to Aprfl 1, 1996 and not located in Systems located in Shoreland or Wellhead Protection Shoreland or Wellhead Protection Area or Serving a Food, Areas or Serving a Food, Beverage or Lodging Beverage or Lodging Establishment Establishment, or systerns Built after March 31 1996 Is the svstem an imminent threat to public health or Is the system an imminent threat to public health safe ? (a yes answe�is an ITPHS system) or safetv? (a yes answer is an ITPHS system) -Discharge of sewage to the ground surface? YES NO - Discharge of sewage to the ground surface? YES -Discharge of sewage to dralntile or surface waters? YES NO -Dlscharge of sewage to draintile or su�face waters?YES -Sewage backup into dwelling? YES NO -Sewage backup into dwelling? YES 0 -Situation with the potential to immediately and -Situation with the potential to immediately and adversely impact or threaten public health or adversely impact or threaten public health or safety? YES NO safety? YES � Is the svstem failina? (a yes answer is a failing system) �s the system failing? (a yes answe�is a failing system) -Less than 7W0 feet of vertical separatlon between - Less than THREE feet of vertical separation between system bottom and saturated soil or bedrock? YES NO systern bottom and saturated soil or bedrock? YES -A seepage pit,cesspool,drywell, or leaching pit? YES NO -A seepage pit, cesspool, drywell, or leaching pit? YES Is the svstem non-comaliant? Is the svstem non-c�mpUant? - Is the system regulated under a monitoring plan or - Is the system regulated under a monitoring plan operating permit? (if n�,go to page 2) YES NO operating permit? (if no,go to page 2) YE� 1/yes, !f yes, -Has the required monitoring taken place? YES NO - Has the required monitoring taken place? YES No (If no, the system is non-cornplying) (!f no, the syslem is non-complying) - Does the monitoring indicate ihat the system meets - Does the monitoring indicate that the system meets performance expectations? YES NO performance expectations? YES NO (If no, the system is non-complyingJ (ll no, the system is non-complying) Page 1 of 2 wq-wwists4.31 T 'd Z6ZE—ELS [ZS6l punjpamg ysoC eB0 �B0 SO OE daS