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08118/2010 01:20 7634975011 SPTESTINGINC PAGE 06/08
<br /> Parcel number; Systom status: � Compllant ❑ Noncomplianl
<br /> � ���� � (es datonninod hy fhis Form)
<br /> M�#ydraulii� Peri'ormanc� a��d O#h,er Con�pllance - Compliance Inspecfion l=orm for F_xisting SSTS
<br /> Compliance Issue �1 of �t
<br /> Date oF obsen►atlon: ��5���10_,,.,,, Reason for observatlon: __'Q'���_y��gi4�.�S "�
<br /> This fa�m expires upon next InspPciion or in three years,whiche�er occurs first: _,,,,__ __,,,.
<br /> Comipllance questionslcriterl�: (Required) Verificatio� Method": (Oplionel)
<br /> ..___�Chec►c fhe a�p►apriole box)..„_. ................--..---- fCheck�he apprvpriate box)
<br /> Does lhe system dlscharge sewagc to the ❑Y�s {�No � Searched for a��rfaco outlel�.4p
<br /> _ground surface? ._,,,--- �,,.,..-----.—
<br /> � PorFormed hydreuUc lest
<br /> �oos the system dlscharge sewage to draln ❑Yes ❑ No
<br /> ;,,tlle or surface waters? �._ ,_,^_T_ I� Sear�hed for seeping in y�rd �hc
<br /> Does lhe syslem cause sowage hackup ❑Yes � No � Cliecked for b�ckup in home
<br /> Into dwelling or eslablishment7 .�„,.,.,_ � �xcassive pondl�g In soll system/D-boxes h4�
<br /> Do othor situalions exlsl that have lh� []Yes �Na ❑ I-iomeowner lestimony
<br /> potent�al to Imm��ialely�nd aduersely
<br /> impact or threaten publlc health or safety I� E�camined ior surging in lanlc
<br /> �electricel, unsaie covers, otc)? _,..,..,, � "131ac1c soil"above soll dlsp+�rsal syslem�Q•
<br /> Any"yes"answer indlca(ws that th�s,ystem Is an Imminent
<br /> tl�rcAt to pR�brfc heafih and safQty. ❑ System requlres"omergenGy"pumpinA
<br /> �.-...,.._- .- ❑ Performed dye test
<br /> Doos the systom pose P threat to ground I]Yes �]No
<br /> wate�for any condlllons doomed non- ❑ Other: �_____ ___,_ ,„_
<br /> ,.�rolecQye as determin@d h ihe ins ecic�r'T ,,,,,y_
<br /> "YQs"indicates thet fhe systent!s failing to protect �,^�_ _
<br /> ground wmter.If"yes; a+escrl�e t��e�ondition noted: �
<br /> 'No standarti pratocof exists. 7'his lisf is nof exhaustive,
<br /> ___..._._..____�_ ._....,._._— — ;n sequentia!order, n�rdoes it indicate which '
<br /> coinbfnatlons ara necassary to meke thls rlefertnination.
<br /> Certificativr�
<br /> This form is to be complel�ed and alta�had to the Summary Form af the Minnesota Pollullon Control AAency's(MPCA)Gomplianco
<br /> Inspection�Qrm fo��xisting S�ubsurface Sewag�Treatment Systems. Observations, ipterpretatlons,aiid conclusions musl be
<br /> completed by an inspoctbr. CoMpleted form must be submltted to the local unit of govemmenl wlthin �5 days.
<br /> Properiy owner name(s): '�Q�1¢1�..�'�i�,�/��,''f.,,.,.,,.,:_�_
<br /> I�roperry address: ......:�I_3_����-.�'o�1�����..1�Q. C��O�10 _._�
<br /> Properly own�r's address(If dlf�erenq; „ ,. ,,.,,,, _.__ _,,,,,.-_ ___.__ �,_,_
<br /> Counly: ��;��.��l?-4 ___— Prope�ly owne�phone: ��,_�._`�k0_--.�(Q�r ___.,..,,,,._
<br /> 1 her�rby certilj�Ihat 1 personelly mado th�o/�servAtrons, interpretations, and conclusions r�epo�ted on this fnrrn and tPiet they er�
<br /> ca►recr.
<br /> Name: S'���hltr� � � V '1"'r s:_''�..`.�_ Ce�Qflcatlon number. los',��1.,,.,,.-- ---.,_.,--�—
<br /> )�(,�_�....,�_l.�-
<br /> Dusiness license name and n�ambor: S -� '��i�r;��,u(a IF+�,`. � L.�1'rr� ;���__._`��1. �`� ' '�1, '�� -•��1 � 'ry 7.,.��!���or
<br /> SI natu�e� u il of government:
<br /> Namo of locol _„_
<br /> __..................:..... .......-- -...__._„_..:.
<br /> ' 9 � ,_.._,_���z...--�-� ....,,___— Date: �,,..~`��a� a..
<br /> www.pca.slate.mn.us • 651-296-G3U0 • D00-657-386�1 � T7'Y b51•282-533z or BAO-657•3864 • Av�llabl�in al�einative FQrm�ltS
<br /> wa-wwists4-31 • 4/2�/09 Pa¢e 1.of 8
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