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Parcel numbec Sysiem status: ❑ Compliant � Noncompliant <br /> - -- __ ---- <br /> (as determined by thrs form) <br /> Hydraulic Performance and Other Compliance - Compliance Inspection Form for Existing SSTS <br /> Compiiance Issue #1 of 4 <br /> Date of observation: q -�D- Reason for observation: t� ,/�, <br /> -- p9-----=-- \'�'0 i 5,4'`i`� �C'"F'},�91 ca�j`y=�-. <br /> This form expires upon next inspection or in three years, whichever occurs first: <br /> Compliance questions/criteria: (Required) Verification Method': (Optional) <br /> __�Check the appropriate box) ___ _ (Check the appropriate boxJ <br /> Does the syslem discharge sewage [o the ❑ Yes 0 No Q Searched for surface ouUet p•�� <br /> ground surface? <br /> Does (he system discharge sewage to drain i ❑ Yes ❑ No ❑ Performed hydraulic test <br /> tile or surface waters? � Searched for seeping in yard*1� <br /> Does the system cause sewage backup ' ❑ Yes � No ❑ Checked for backup in home <br /> into dwellinq or establishment? _ ( <br /> — � Excessive ponding in soil system/D-boxes la0 <br /> Do other situations exist that have the � ❑ Yes � No <br /> potential to immediately and adversely ❑ Homeowner testimony <br /> impact or threaten public health or safety ❑ Examined for surying in tank <br /> _�electrical, unsa(e covers, etc.)? <br /> An e - ❑ "B�ack soil" above soil dispersal system <br /> y"y 5"answer indicates ihat f/�e system is an imminent <br /> threat to public health and safety. ❑ SyStem requires"emergency" pumping <br /> — -- ---- — ❑ Performed dye test <br /> Does the system pose a threat to ground � ❑ Yes � No <br /> water for any conditions deemed non- ❑ Other: <br /> _protective as delermined by the inspector? i <br /> "Yes"indicates that the system is failing to protect <br /> ground water. If"yes", describe the condition noted: ------ <br /> 'No standard pro(ocol exists. This lisi is not exhaustive, <br /> — ------- — — ---- in sequentia/order, nor does il indicate which <br /> ________ _ _ ___ _ __ combinations are necessary to make this defermination. <br /> Certification <br /> This form is lo be completed and attached to the Summary Form of the Minnesoia Pollution Control Agency's(MPCA) Compliance <br /> Inspection Form for Existing Subsurface Sewage Treatment Systems. Observations, interpretations, and conclusions must be <br /> completed by an inspector. Completed form must be submitted to the local unii of government wilhin 15 days. <br /> Property owner name(s): v 0'i��; �e r�y,��bl (���,L��Z,,�( f! <br /> Property address: �2.SU r"i c'i 1 L��-�- l..-��`! �=.-- 'C���a ta � �4�3-ti�? <br /> Property owner's address (if different): <br /> County: �-} �=�..1}.1�t�;'14-� Property owner phone: ry��7 - �5.+.}cy ~ �cj L��j _ —— <br /> I hereby certify that 1 personally made the observations, interpretations, and conclusions reported on this form and that they a�e <br /> correct. <br /> Name: _r-�{��/l��y �• S��..�.,��,,���c,, Certification number. (,a� <br /> Business license name and number: �-���irya��U\� ►�C , �� ,�4�. i_���,..�g ��'3c, �,�, o� <br /> Name of local unit of government: <br /> Signature: r_ '�,.- - (_.r� �.:� (s� -- �'1 —1 <br /> Date: � vo� <br /> www.pca.state.mn.us • 651-296-6300 • 800-657�386��,• TTY 651-282-5332 or 800-657-3864 • Available in afternative formats <br /> wq-wwists4-31 • 4/10/09 � Page 2 of 8 <br />