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05/27/2011 02: 21 7634975011 SPTESTINGINC PAGE 68/11
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<br /> Parca.l number: . __ � _ __ Sysiem sta�tus: � Com liant I
<br /> �' �---' - p I] �loncompliant
<br /> ' (as detem�inp�l by ll�ls fonn)
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<br /> Hy�lra�u9��� Pe�#qrmanc�e a��d O�;h�r�Camplianc�e— Compliance lnspection Form for Existing SSTS ,
<br /> Complian�e Assue #1 of q� �
<br /> Dr�18 ofi obsenration: _�J(a-a0_1..1�_.,.._ i f�eason for obsen►etlon� / � I
<br /> �'��.�-�.yS�C�
<br /> 7his form explres upon ne�d insper,tion or In three years,whichever occu�s firs�t: J
<br /> .--,,... -• - - - ..—.. ,
<br /> Corneppanc�e a�uestioraslerifieria; (Required) � �/erificati�on Method'h; (Optional)
<br /> __,__.,_(Checlrthe appr�pnele_boxf ,._,.,,._ ___,�_ (Checic th�appropriate box)
<br /> Does Ihe syslem discharge sewage to 1he ❑l�es (�.I�o
<br /> �round surface? �I Searched for surFace outlat u0
<br /> - ----- -- -.. —.......�— _...�
<br /> Does the system discharg�sewAge to drafn ❑Y'es [f No C� �'�r�ormed hydraulic lesi
<br /> _tile or surface waters. � Soarched for seeping in yard►�J
<br /> �
<br /> � "-_""i.. �....��__._.A._._ ._.'._
<br /> Does the system cause sewage b�c4cup ❑v'es � No [I Cl�ecked for backup in home
<br /> _Into dwellin�or establishinent? ;
<br /> ^ �`— � - �- � - •• - � E�ccesslve ponding in soil sy�tem/D-boxes p►�
<br /> Do other situaUons exisi that have the ❑V'es � No
<br /> po#entlal to immediatoly and adversely ❑ Homeowner testimony
<br /> Imp�ict or thrQ�(en public health or saf�ety ❑ Examined for�urging in tank
<br /> _�electncaf, unsafe covers, �lc, ? '
<br /> ...... ��_... .._.�i
<br /> Any'"yes"�rnswer indicates th�t the s,yste,m is an bmPnin¢nt � ���lack soil"above soil dispersal�ystem h10
<br /> tbneat tv pie6oic he�lth and saiofy. ❑ System roquil'es"emargenCy"pumping
<br /> �-- -------- -••--�_,_ .. i ...— ❑ PerFoRned dye kest
<br /> Does the system pose a threat to ground I]Yes �) No
<br /> water fqr any condiifons deemed no�- � ❑ Other; __
<br /> . ..... ...,.
<br /> _protecti�e as dateRnined by ihe Inspoctor7 _,_ __ �"i
<br /> 'rYes"irpdicet�es that the syst�m is i`a01ir1g to pr�!l�ect "��. _,� -- �-'--� -----
<br /> ground wai�er./f"yes", desr.rl�e tf��condli/o,n vioted: '"••'•— -��--- • - ,
<br /> ' •No sf.andard protocol�xists. This lis�;s no[exhaustive,
<br /> '"�--�-� � " --- ��- -����-•- -- ��• �••- in sequ�ntial o►der, nor doQs it indfoAte which
<br /> _ 1 _ r.ombinetions a►�e necsssary to rriake thls determination_
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<br /> Cer�ifica�ion ! ;
<br /> This fqrm is to be compleied and aitached to the Sl�mmary�orm of the Mlnnesota Pollution Control�goncy's(MnCA)Comp4ance
<br /> Inspectia�Fortn for Exlsting Subsutface Selnoage Treatment Systeme. Observations,int�rpre�tations,and conclusions must be
<br /> completed by�n Inspeclor. Completed form must k�e submitted to the local unit of government within 15 days.
<br /> F'roperty own�r name(s): �����(�,�. 'ru�_�,� _ _
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<br /> Propc�tyacldress: ��l.n��l�,��'�r._.Pl.%�"�'�,►�.�'��G:7 _,,._ -_.,._..._ �
<br /> Property own�or's address(if different)� .__.�l_.__„ '
<br /> ,�...r —......_._ „�,.. -.--•w�- --..
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<br /> Couniy: .,I����t�l�.....-- -.. . Property owner phone: J°.�2� ��5.-" e1 a f�7,,....._
<br /> 1 her�rby certifjr fhat!persqnally mAde thg observa�lons, interpr�tations, end canclusions reported on thls fo�m end that they a�e
<br /> r,arect. '
<br /> Namp; �;-��i�����._ y:�_`c.���,�� ,,},� ��q��, Cerl'Ification number: d �1 '
<br /> .. �e� . ..
<br /> Business license name and number: S - �����r-�I r- �'L., ►h1 C . „1�,����}4..��y_I�'�21r��IJ�1 ��1 , or
<br /> _..,:__ .. ��a�.� ..l 4',�,
<br /> Name af I�cal unit of go�rernmon4; ; ,
<br /> f� - _.,. -- —.,._.. ..... __,..._ -..
<br /> .._.
<br /> •---- •,,.—_;
<br /> Signature� � , Date: � �
<br /> ----: _._�_ � z--.-,----. , ���-���.
<br /> �-.� .. . _
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<br /> www.pr.a.statP,mn.us � 651•296�6300 � 800-�57•3964 � TTY G51-282-533z or 80p-b57-3B6Q • Avaitabl�in alternAtive f�n„ar�
<br /> um.wuiieFrA_7i _ A19�Inn �
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