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FROM : R''i� PHONE N0. : 4422091 Oct. 29 2002 01:25PM P2 2/25/OZ water/Wastewater-ISTS4.31 � Compliance Inspection Form for Existing Individual Sewage Treatment Systems Minnesota Pollution i� Control Agency Cvmpleiion of this farm fulfills the minimal requirements of Minn. Stat_§ 115.55(2001)and Minnesota R_ ch. 7080(�s99�, Please refer to local ordinances for olher requirements or informatlon, especially for compliance requirements for bedroom additions. General• Date of ihspe�tion:,� �l�Z Reason for inspection: � �iiv Property Owner(s)_� _��itl� I]i� Telephone � �73- �-s G 7 Person requesting inspection SA�n � Telephone ( ) Site Address ZZ 5�S �2�JGl�„ �A�e� ,�c� City f.vAy2A�i9 Zip Cade S'.s'3Q/ Fire No./ Parcel Nv. County�N�)��!��-� � Township '�"` - Legal Description Local Regulatory Authority Date system constructed �'�' � System in Shoreland Are yes o System in Wellhead Protettion Area: ye no S�/stern serving a MDH licensed facility: y no Local Permit# (if any) 89S"� Systems built prior to Apri! i, 1996 and not located in Systems located in Shorelahd or Wellhead Protection 5horeland 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 publi�health ar Ys the svstem an imminent threat to public health safetv� (a yes answe�is an I7PH5 system) or safetv? (a yes answer is an ITPHS systemJ -�ischarge of sewage to the ground su�face7 YES NO - Discharge of sewage to the ground surtace? YES O -Dlscharge of sewage to draintile or surface watersl YES NO -Discharge of sewage to draintile or surFace waters?YFS N -Sewage backup fnto dwelling? YES NO -Sewage backup into dwelling? YES -�tuation with the potential to immediately and - Situation with the potential to immediately and adversely impact or threaten public health or adversefy impact or threaten public health or safety7 YES NO safety? YES� Is the svstem failinq? (a yes answer is a fai/ing system) �s_the system failinq? (a yes answer is a fai/ing system) -Less than 71N0 feet of vertical separatfon between -less than THREE feet of vertical separation between system bottom and saturated soil or bedrock? YES NO system bottom and saturated soll or bedrock? YES -A seepage pit,cesspool,drywell, or leaching pit? YES NO -A seepage pit,cesspool, drywell, or Ieaching pit? YES Is the svstem non-compliant? Is the svstem non-com�liant? - Is the system regulated under a monitoring plan or - Es the system regulated under a monitoring plan or operating permit? (it no, go to page 2) YES NO operating permit? (if no, go to page 2) YES,� If yes, If yes, -Has the required monitoring taken place? YES NO - Has the required monitoring taken place? .. (If no, ihe system is non-complying) (If no, the system is non-complying) �Does the monitoring indicate that the system meets - Does the monitoring indicate that the system meets performance expectations? YES NO perfOrmance expectations? (If no, the system is non-complying) (If no, the system is non-complying) Page �. of 2 wq-wwi�4.31