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11/05/2010 63:55 7634975011 SPTESTINGINC PAGE 08/10
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<br /> Parcel number: ____ ___ _ _`_ _ System status: � Compliant ❑�loncomplfant
<br /> (as defe►minQd by thls fomt)
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<br /> Fly�lmauufic IP�r�nrimance �swd Oiher Com�l�ance -- Compliance Inspecfion Form for Existing SSTS
<br /> Compliance Issue #1 of 4
<br /> Dr�tp o'f obsenration: �� ����.pJ� __ Rearon'For obsenration: �"�!._��+..�_ �('��,`��
<br /> Th)s form expires upon ne�d inspection or in thrae yeara,Nrhichever or,c.urs first:
<br /> C�rrnpliance questlons/�riteria: (Roquired) Veriflcation Method�: (Optioneq
<br /> .__(Check the eppmpriate box� .__... ,., , _ (Check the Appropriafe bc►n)
<br /> Does lhe system discharge sewage to th� ❑Ves �No
<br /> ground surface? � 5earched fo�surface o�dlet N�
<br /> _........... .......-- �-----,,...,,.....,_- —
<br /> [� P�srformed hydraulic t�st
<br /> boes the system disch�rge sewage to�rain ❑Yes ❑ No
<br /> tile or surface watD�s? _____ _ [� So�rched for seeping in yarcl
<br /> Does the sy3tQm cause sewage backup ❑ Yes � No � Checked for bacicup ln home 1��
<br /> into dwellinc�or_establishment7 ___,___..__,.,.,. _______ � Excessive ponding in soil system/D-boxes 1SQ
<br /> Do other siQuations exist that have the [J Yes � No n Homeowner testlmony
<br /> pq�ani;ial to immediately and ad�ersely
<br /> imp�ct or threaten p�iblfc health ar safery [7 Euamined�for surging in tank
<br /> ._�—.�___._.. ,�.covers,etc_)?
<br /> eleckrical unsafe
<br /> -�--- � "Dlack soil"abovm soil dispersal system N�
<br /> J�ny y�s answe�indica�es Phat the system/s an im�r►Inent
<br /> threat to puaallc he�/!h arod sRfaty, ❑ Syslem reqUires"emergency"pumphlg
<br /> _......,_...--- �---._..........,.._
<br /> — -- P�rformed dye test
<br /> Doos the system pose a threat to ground []Yes � No � Olher:
<br /> water ftu any conditfons deemed non- ----••�•-�--- --••- .•.---;
<br /> __protEctive as determined by ihe inspocto� '
<br /> ..,--- .._. —,..--- „ ..�
<br /> "Yes'"indf�cate�that thQ sy�tem fs falling to protect
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<br /> gro�n w�ier. f"yes", d�seribe t�e condPtion noted:
<br /> 'No standarrl protocol exists. Tl�is list is not axhausliv�,
<br /> .............••-- ----._. . --- ---.._.......... .........._ in sequentiel order, nor does it indic�#e mrhlch �
<br /> r,c�mbinetlons ere ner.�ssDry to make lhls d�t�rminaflon. '
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<br /> Ce��i'Fi�al:�on
<br /> This form 1�to be cvmpleteci and attached to the 5ummary Form o�f the Mlnnesot�Pollution Control Agency's(Mf�CA)Compliance �
<br /> lnsp�ctlon Foren for Existing�ubsurface Sewage Treatment Systems.Observatlons, intorpretations, and concluslons must be '
<br /> completec�t�y an lnspeeter. Completed form must be submltted to Ihe local unit of govemmont within 15 days.
<br /> Propeny owne�name(s): _��pg,L�_�►.�_y��1.4¢��( '
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<br /> Property address_ _a.r�r-9�''�'�G�___G���. G���L��- G�pJS.p
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<br /> Property owne�'s address(�td�r�orent)_ .. ,,, „ '
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<br /> County; �r�����1.�( Property owne�phone: (D1Z-2�-_I�`t�_�'. .•--. _....... ,
<br /> I hereby cerllry that 1 pPrsonally macle lhe obsenietlons, lnterpr�itations, end conclusfons reported on this fnm�and fha(they ar�e
<br /> r.orrecf.
<br /> Name: " f ," .�' I
<br /> "�"1:���/.rc;3��(1�'��.�1�•�1�1�'�`e., Ccrtification number: �,�,Z') __. , , - --
<br /> , _ _ __.... _.... ...
<br /> ousiness Ilcense name and number: S -P'����r�'�r,L-!_I�.1�` , 1.�.01�,. ��';;;w��...� 'V°t�l�h�'Zj����'"1_::�'.��,��,ar ,
<br /> Nemo of Iocal u it of govcrnment; �
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<br /> Signature: _..___ 'U"> � � .,..--- - Date: ����"c1o)O �
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<br /> NMIW.pC�.St�te.mn,uS + 651-296•63pQ � SOO��i57-3864 . 77Y h51-�R7-5337 nr NM-��,7.�R�,tl . A��ailnhlp�� olFcrn�tfi.�r,......�.
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