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07/08/2011 01:16 7634975011 SPTESTINGINC PAGE 64/09
<br /> Parc�l numbe�: „ __ „_._ „ System status: �Compliant �Noncompliant
<br /> _.._..__. ..---..--- •- (As determfned by this fbrrrr)
<br /> k#yd�aulic ��t'fa�rtn�nc�a �nd �i#her�ompllanc.e- Compllance/nspecfion Fo►m for Existing SSTS
<br /> Compliance Issue #1 of 4
<br /> Dete of observation� ,.�a,,_�Q�L.,__._ Reasnn for obsenration� ,���.,,!��'�5��__ —
<br /> Thls form expires upon nexl in�pectlon o�In three years,whichever occurs first: __�, __ ,,,.� _
<br /> comp�t�nce questlo�s�c��terla: (r.equired) Verificatlan Mexhod*: (optional)
<br /> �Check fhe ap�rieAe b��___ ,,,_.--.— (Check the spp►oAri�#e Gox)
<br /> Does the system dlscherge s�9wAge tb thg ❑Yes �'No � 5ear�hed fo�surfeCt3 nutfet 9.1D
<br /> --ground surFece�.---- .,. —,:.-.--
<br /> ---•-��---- " ❑ PerFormed hydrauflc test
<br /> �oes the s,ystem dlsche�Ae seWege ta drain ❑Yes ❑ No � Searched fnr seeping In yard 1•1a
<br /> _tile or_surFace waters?_._..-----.�_.-----...�-._..-- .: —
<br /> boes the system cause sewage backup ❑Yes � Ido [� Checked for backup in homQ
<br /> _into dwellin or establishmenY? _,_____��_ � ��`^^� (� Excessiue ponding in soi{system/p-boxes �0
<br /> Oo other s'�tuatinns exls�that have the ❑Yas � No Q Womeowner testlmony
<br /> po#ential to Immedl�t�ly and adversely
<br /> impact or thr2etbn publlc health ar safety ❑ Exa,mined for surging in tank
<br /> ,,,(e►ectricel, unsafe covers etc. ? , _ �__._ � "Ble�ck sall"s�bove soll dispersal syatem tiSfl
<br /> Any"y��"gnswoer fndkaMs H�at!�e sysfem�s an imm/nPnt
<br /> threatto publlc Nra/M�And�afiafy. ❑ Syst�m requires"emergency"pumping
<br /> --- -....., ..----�--.. ,_.- -- ._-- ❑ Perf�rmed dye test
<br /> Does the�system pose A threat to grnund �YQg ��o ❑ Other: � _— ____.___„_,._,_..
<br /> water for any condltions deemed non-
<br /> --�ratective as determined y the Ins�ecto�? _,_ —.� . •• ---... �-. —
<br /> "Ye�s"lndicai�s that ehe system!s fr�lling ito pro[ect .. — ------
<br /> grvund water.If"ya,s';deseribe the condiHon noted: �No standa►r/protocol exlsts. This llsf!s no(�exhausHve,
<br /> ..__.�........-----�. .... —... . ----
<br /> __._.___ _w...,.--.-- in sequen6al orrler,nor does it inAir.ate wh�h
<br /> � combinetions a►e ner,essery to make is detertnrneflon.
<br /> Certification
<br /> This folm is to be aompleted and st#aChed to the Summ�ry�omt of 4he Mlnnesot�Pollution Cantrol Agenoy's(Mf'CA)Compliance
<br /> Inspeetlon Fortt�for Exi�ting 8ubsurFace 8ew�ge Treaiment Sys6ems.Observationg,Interpretatio�s,and conclusions must be
<br /> completed by an Inspector.Completed form must be submitted ta 1he local unit of govamment within 15 days.
<br /> Property owner n9me(s): �j_,Lllf�.......__1�I:���.h._ _ Y --_ ,...—. ..- —
<br /> 4 c. _ �Sc��`�:.�,'� 4�c�-�.,.
<br /> Properly address: --) 3 C�U_�!�.5�.��.... S�—"... .��
<br /> Property owner's gddress(if dHk��rent): __ ..:--.._—.._...._...__..�___
<br /> —...._�...—
<br /> ..,..._ . .,.� �. �
<br /> Goun ' Prop�rty owne�phone; �Z-.��"_��L....f� �f�.�_...._ .�,....._.
<br /> tY� ..����.��_,,,_—_. _.� •
<br /> I h�r»by cerfify that I pm►sonally made the obseiv�6ons, inte►p►ef,etions,end conclusions repo►fed on tV�ls form ancr that they ere
<br /> co►rccf.
<br /> �"�(�i�L�cT.�:—'�i_ �L1:S��M��'S Certificatlon number. _f��� .w.--..----.....�.,.....----
<br /> Neme: � ,..,_ --,•....__—�
<br /> .__ . ��C �39�_—�-'1-L��a_�'i�l_'1_��_�a.�or
<br /> Business license name and number: S�.P '���L��''�N��,-� '
<br /> Name of I�cel unit of goverr�rq M: } -�� �° "" _ "" �'"'—'-
<br /> —,.,._ _�.—...... _ .
<br /> ��, l.- . �„�: �.....—�„ bate: _��a�0�4�_�....�.__.______.._...
<br /> Slgrteture: _ - ---- -- - �.''--��_.—.._. _..,. . ..--_ ',�
<br /> _.�;1 i�-
<br /> _.,.:_..
<br /> �_._. ..,.� ._.
<br /> ..�----- ._. ..,..._
<br /> . ,..---._....., --.--.�.._---."--"" -" �'.. _.�.. ....o.r.•r+ec• _ A..eilehlo n e 1•om�Fi�ie nnnehe
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