Laserfiche WebLink
Oct 15 09 8: 19a Rndy a Julie Kleindl [9521 -442-9�81 p. 3 <br /> Parcel num er: System status: �Compliant ❑ Noncompliant <br /> (as detem�ined by this form) <br /> Hydraufrc Performance and Other Compliance <br /> Complia�ce Issue #1 of 4 <br /> Date of obs rvation: �6 —�j-Q� Reason for observation: � <br /> This form e�ires upon next inspection or in three years,whichever occu�s first: <br /> Complian�e questions/criteria: (Required) Verifcation Method*: (Optionap <br /> __ Check fhe a �o riate box (Check the appropriate box) <br /> Does the system discharge sewage to the ❑Yes �No Q. Searched for surFace ouUet <br /> __g_round surfaoe? <br /> Does the system discharge sewage to drain ❑Yes � No ❑ Pertormed hydraulic test <br /> tile or surfaoe waters? � Searched for seeping in yard <br /> Does the system cause sewage backup ❑Yes � No ❑ Checked for badcup in home <br /> into dwellin�or establishmeni? <br /> - ❑ Excessive ponding in soil system/D-boxes <br /> Do other sitNations exist that have the ❑Yes No <br /> potential to'mmediately and adversely ❑ Homeowner testimony <br /> impact or th eaten public health or safety ❑ Examined for surging in tank <br /> eledrical,_�nsafe covers, etc_)? <br /> Any"yes"answer indicates ihat the sysfiem is an imminent � �B�ack soil"above soil dispersal system <br /> threat to pu lic health and safety. ❑ System requires"emergenc�T pumping <br /> •- ❑ Performed dye test <br /> Does the sy tem pose a threat to ground ❑Yes �'(No � p�er: <br /> water for an condfions deemed non- — -----�•-•--- <br /> rotective a determined b the ins ecto� <br /> "Y�s"indi tes bhat the system is failing to protect <br /> grQurtd water.!f"yes';describe fhe condition noted: <br /> I 'No standard protocol exists. This list is not exhausfrve, <br /> in sequential oroler, not does it indicate which <br /> combinations are necessary fo make this determina6on. <br /> Certific tion <br /> This form is o be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compliance <br /> Inspection orm for Existing Subsurface Sevrage Treatrnent Sysfiems.Observations, interpretations,and conGusions must be <br /> completed b an inspector. Completed form must be submitted to the local unit of govemment within 15 days. <br /> Prqperty ow er name(s): <br /> Property ad ress: 763 Femdale Road Norlh Orono MN � <br /> Property ow ers address(if drfferent): <br /> County: enne in Phone: 612-781-2321 <br /> I hereby ce " that!personally made the obseivations, inte�prefa6ons, and conclusions reported on fhis foar►and that they are <br /> correct. <br /> Name: A drew Kleindl Certification number: 2926 <br /> Business li nse name and number. Jim's Excavating&Pumping, LLC or <br /> Name of I I unit of govemment- Carver un <br /> signature: Date: /�-/,3�d'�J <br />