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i-'�i�'�� ilUl"!IhEI": — _ -- �-------_ System siatus: U Cornpliant U Noncompliar�t (as clefermined by this form) . � � ___ �i��a�� .� �-S'i , i:c _ + ..�:��:=_- _ _ ?sa '�aL!a �` ... Date of observation: Reason for obseniation: This rorm expires upon ne;:t inspectio�i or in three ;�ears,�,vhichever occurs first: Com�li��ce qu�s,fo:�s/criie;iU: (Required) tie;ii'icaiic�n ivie�'hoc;`: (Optional) Check fhe a ro riate box) --� (Check the appropriate box) Does the system discharge s�wage to the ❑`(es �o round surFace? Searched for surface outlet Does the system discharge seU�age to drain ❑Yes _ iVo ❑ Performed h;✓draulic test tile or surface�,vaters? �earched for seeping in yard Does tiie system cause se�r.�age backup � ❑Yes No ❑ Checked for back��p in home into d�n�elling or establishment? -- ❑ E;:cessive ponding in soil s;�stem/D-boxes Do other situafions exist�haf have the ❑Yes No poten'tial to immediately and adversely ❑ Homeo�vner testimony impact or ihreaten public health or safety (electrical, unsafe covers etc)� ❑ Examined for surging in tank �'''�„,",Qs a �,.,� ir,-'ica�es r>,:. � s��--; • ❑ "Black soil"above soil dispersal system : . � � -.-7��>e$....3f $�.7 IIJ`P'')i?�/�C eheezf to prjblic f;2alth and safeiy. ❑ System requires"emergency"pumping - ❑ Peifion�ned dye tesz Does the system pose a threat io ground I r"es � n n � �r�o �( Oih�r� /Q�ll sc wFJ/ A��% v✓ater for ami conditions deetned non- ' � r � S protecbve�s determmed by the inspector? +I q�( �y �� / A'( � - -- — __ �— ,`;�c.s ;-t,rr F :�c��ilw S;iSYe;i;15 7"2fI%I7C�iG f�1'OlEC; ---- ,'1'Qfl!+f��<^Yr,' iT"'7�S",r!nSC„17�? Y,Bg COn4.'iilOz4 t7Q7:6!�r' — -- _ _ __ `No standard protocol exists_ I his/isi rs not e;<hausiive. ----- --— in sequenrial order, nor does it indicate �ahich -- __ combinafions are r�ecessary to make this determination. �:. �: ..�_�...�"� This form is io be completed and attached to the Summary Form of the iviinnesota Pollution Controi Agency s(iviPCA)Ccmpliunce ii�s�ec�ior, t�r;�;or F,is�;;�g Subsur��_ce Se�,v��g�Tr�at�nenf:Sys�ems. Obsen�ations, interpretations, and conclusions must be completed by an inspector. Completed�orm inust be submitted to the local unit of government within 15 days. Propert;✓o�vner na�r�e(s';: Prcperi;�address: �f�� ,y� „�o� � s7�r --- ir Property o�r✓ner's address(if diiferentj: Co�mty: �c.4.` Phone: /hereby certify ihat/persona//y made the observatlons. inferpretations, and conc/usrot�s reported on this form and that they are correci. Name � �,.�,v �___�_�� Certification number: �� Business license name and number: /yjiS ,`,d - �' e 5�� Z/ or i�lam�of local unit of govemment: O �,� Siynature: --fdc` - - - — - — _ Date: D i /p --- f�-- wq-wwrsts�-31 Compliance Inspeceion Form for Existrn� SSTS �l1/08