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11/6212010 21:25 7634975011 SPTESTINGINC PAGE 64/09
<br /> Parcel numher: •
<br /> --�- -- � - -- Syslam skalus: �Compllant 0 Noncompllant
<br /> . - (es dote►mingd by ll�/s form)
<br /> �yd�rauUo� P�r�ornaanc� and othe,�r Compl�ance — Gompliance 1�7spection Forrrr for Ekisting SSTS
<br /> Corr�plyanc,e Issue ,�1 of �
<br /> D�te of observation: _oj._-1���,��____ Reason for obsenralion:
<br /> .�Q�'����������
<br /> 'I'his forrn expires upon naxt insp�ctlon or in tl�ree years,whicheve�oc�u�s first: � ���
<br /> , .._ _,,.__
<br /> ..----- —
<br /> Compl9ane�question�lcrite�ia: �Requ;�ed) Verification Method'": (Oplional)
<br /> Does the systam dlscharge s ox— (C��eclr thP a
<br /> _ __Check thQ_a[propriate b
<br /> ewege t�the ❑Yes �---�-- - p'°�°p����hox)
<br /> _ground surface? ___ _ �No ❑ Searched for s��rFace ouilet
<br /> Does tl�e system dlscharge sewage to drain �]Yes �] No � �'��ormed I�ydreulic teal
<br /> _tlie or sutface waters? ,, _ ,_ _ _ � Searched f+�r seeping in yard I�L�
<br /> boes the system cause saw�ge backup �]Yes �No � Checked for backup In home 1�.1'�
<br /> into dwelling_or establlshmenl?
<br /> .,
<br /> "-- �-�---��°� � I� Excosslve panding in soil systom/D-boxes p�
<br /> Do olher silue�lfons exist that have tlie ❑yeg
<br /> potenti�l to itnmedlately ancJ a�lvPrsely �N� ❑ Homeowner testimony
<br /> irr�pact or lhreaten public health ar saFety ❑ Examined for surping fn tank
<br /> _.,(�lectrical, unsafe r,overs etc. �
<br /> -��._..
<br /> Any"yes"�nswer indicatzs that the system Is An imminent � '��leck sc�ll"above soll dispNrsal syatem ,1�,(Q ,
<br /> thro�t to publlc heA/fh and s�lCty. ❑ System requil'es"emergenay"pumping
<br /> - "" -_ '._ ❑ PerFormed dy�tes!
<br /> Does the system pose a�hreAt to ground []Yes [�No
<br /> water For any condilions deemed non- ❑ Other:
<br /> -------. _...
<br /> _..._—...,.—..._
<br /> _ ro ec_ve as determi�ed by the„inspectoi-'7_ _y �
<br /> ^Yes"indlcates that th�e systam Is failing to prote�ct � " -
<br /> qround wate,r. If"yes", describ�the c�nditinn not�d: --•�- -��------�-.
<br /> 'No sfa�darY/prDtocol exists. TI�Is lisf is nof axl�austive,
<br /> -.. ."" --- .. in soquentia!oMer, nor does it i��dlaat�whlch
<br /> --•�... ` combina(lons ar�necess9ry M malse/his determinetion.
<br /> Certific�t�vn
<br /> This form is la be campleled and attached fo ihe Summary Form of lhe Mi�nesota Pollullon Cvntrol Agency's(fu1PCA)Compliance
<br /> Inspectlon Forn�for Exlslfng S�ubsufface Sewage Treatment Systems.Observetions, inlerpret�tions, and conclusions musl be
<br /> compleled by an inspector, Compl�ted form musl be submitted to the local unit of government�nrlthin 15 days.
<br /> Praperty ownor name(s): _�(A.�_ Gt� q_�����„���,,�,���
<br /> .. ___ --
<br /> _..,,..—..----
<br /> Properly addr�ss: -._.�.��___�a��1�'_.'.1,��J�1�� '�J,�,.�3��---C7��%�..���
<br /> ....- ----... ...
<br /> _.-
<br /> roperly ownar'r�ddtess (iF differon�):
<br /> � _...-- • -_ _ ,.
<br /> ., __ ,.,, _.,
<br /> County� _���p.�_�'�1_9.� ,� Properly o►Nne�phc�ne; °1 J�i�,.��(,7`�-l._���,. •-
<br /> �her�by certify that I personally mado fhe observationq, �nr��►�rairons, and concluqfons repartPd on Fhis irnm and thef fhQy are
<br /> r,orrech.
<br /> Name; -S'���>r/_�Y�.� � ' �; '�
<br /> Y����..G,1-�1�1�'��,,> _. . Certlfication numbor, �,;a�)
<br /> _....,.
<br /> buslness liconse namo and number. S �C� �°('��.r���(., 11,l�.,� 1..�.(.,��.���. o yr , , � � _., � •----~..-
<br /> �ti t_�,.:���_�t�...�'�„� a,�.,
<br /> , 6. , or
<br /> Name of local unit oE over eni:
<br /> ��•-. � � ... ....
<br /> �� _.
<br /> Signalure: � - ....-- -�., ---,...
<br /> .._—...--
<br /> - _'�-�-° .. _.. Dete: ,.,9����52/.,C��, _
<br /> �-- � --� -.__ _.,. _.,.
<br /> www.pca.state.mn,us • �i51•296-b300 • app-657-39b4 • TTY b51-26�-53�z or 800-h57-3a64 • Availahlc in alternative Formala
<br /> wq•Wwists4•3f • 4/24/09
<br /> R__,.. � ...
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