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� y� � �� ��'` , � � _ �. ,;,� � �', 2/25/02 Water/Wastewater-ISTS4.31 �� Compliance Inspection Form for Existing �■�K Individual Sewage Treatment Systems Minnesota Pollution v Control Agency Completion of thrs form fulfills the minimal requirements of Minn. Stat. § 115.55 (2001)and Minnesota R, ch. 7080(1999). Please refer to local ordinances for other requirements or information, especially for compliance requirements for bedroom additions. General: Date of Inspection: %� '�'�'`� Reason for inspection: ,�� 1�v Property Owner(s) �1 e�t nll.? �,'.1�"�S��n.` Telephone (G;I� ��'� ��y7 � Person requesting inspection _ �� c Telephone ( ) Site Address I�( �-� ��x �"� City Zip Code Fire No./ Parcel No. County N��=`�� Township �-��<-�'��n Legal Description Local Regulatory Authority Uate system constructed /�•��/ ^ �5 System in Shoreland Area: esy no System in Wellhead Protection Area: yes n�.r System serving a MDH licensed facility: yes �Local Permit# (if any) Systems built prior to April 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 systems Built after March 31 1996 Is the system an imminent threat to public health or Is the system an imminent threat to pubiic heai'th safe ? (a yes answer�s an ITPHS system) or safety? (a yes an.swer is an ITPHS system) - Discharge of sewage to the ground surface? YES NO'� -Discharge of sewage to the ground surface? YES NO - Discharge of sewage to draintile or surface waters? YES N� -Discharge of sewage to draintile or surFace waters?YES NO - Sewage backup into dwelling? YES N0, -Sewage backup into dwelling? YES NO - 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 pubfic health or safety? YES J0 safety? YES NO Is the svstem failin4? (a yes answer is a failing system) Is the svstem failing? (a yes answer is a failing system) - Less than TWO feet of vertical separation between -Less than THREE feet of vertical separation between system bottom and saturated soil or bedrock? YES NO system bottom and saturated soil or bedrock? YES NO -A seepage pit, cesspool, drywell, or leaching pit? YES � -A seepage pit,cesspool,drywell, or leaching pit? YES NO Is the svstem non-compliant? Is the system non-compliant? - Is the system regulated under a monitoring plan or - Is the system regulated under a monitoring plan or operating permit? (if no, go to page 2) YES � operating permit? (if no, go to page 2) YES NO If yes, If yes, - Has the required monitoring taken place? YES NO - Has the required monitoring taken place? YES NO (!f no, the system is non-complying) (!f no, the system rs non-comp/ying) - Does the monitoring indicate that 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-complying) (!f nq the system is non-complying) Page 1 of 2 wq-wwists4.31