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P�rcel n�amf��r: _ 5ystem status: �Compllant � Noncomplf�nt
<br /> --.. __ -�m--� (�5 dePEttrnlned by f1�is fr�m7)
<br /> R�y�1rt'�t�rec Pe�-f�r�nn��ce ��d Ot�h��r Compli�nce
<br /> C�mpliance lss�e #'t caf �€
<br /> pa�e of obsnrva{lon: __�_) --Q� Rea,an for obseirvaklon� ��"�"~"�� �����r�"�_,_..— —�--.-_ ...
<br /> Tl,is iorm vxpires upon next inspection or in three years,wh;chever oocurs firsl; _�,s'__}= C��, 11 ...,—
<br /> C�mp�Banc� yuestBonslcriteria: (f��quired} Ve�'ificatqart Metht�d'`: (4pti4r�ap
<br /> {�h�c1c the a�>>�riAfe b�x) ___ (Gh�c1<the approprr'afe box)
<br /> Daes the system disoharge sewage to th� �Yes �}No ❑ �earr,!-nad far surFace outlet
<br /> ground surEace? _
<br /> _'"- .'T ❑ Par�armod hydraulic test
<br /> poes#he system discl�arge s�wag�to dratn �Yes �No
<br /> tile or surFace waters? ..,r _ _ _ � Searcheai for seeping in yarcl4�
<br /> Daos tha system c�use sewago backup ❑ Yes (�No ❑ Chackcti for bacfcup in homo
<br /> _Inta,.,dwelling or establlshmant? � Exaesaive pondfng in soil system/D-boxes N�
<br /> bo otlzer situatfons exist that have the �Yes � Ncr Q Hameorrrner testimony
<br /> polenQai fo imm�di�kely�r�d adversely
<br /> imp�ck ar threaten publlc he8�lth ar sgfety � Examined for surqinq in tank
<br /> ac���Cal, unsafe couers,_otc,)? ,�,_.._. — � "�lack soil"above sall cilspQrs�l systcm�.l� .
<br /> " Ps"arrswer lndfcatos thAt thP syslem!s�r1 ikNtrt�F�lent
<br /> kl�re�+t,tc�pu6Jfc l���lth and sft�fety. CI Systern requlres"'emergenoy° pumpin�
<br /> -.-...�-- - � — ❑ Performecl dye tost �
<br /> Does the system pase a threat to ground [�Yes � Nc�
<br /> water for any cohditions deemed non- � Other: ,w,�_ __
<br /> _protective as determined by,the inspecto� ,,,w„_„�____
<br /> •`1'es"indlcates that the system i�fefling to protect ..._..._-----_ .. ...-
<br /> ground w�ter. !f"yes", describe[�lae crnnditjnn no�ed:
<br /> "No ster�dard protor,o!exists. This Ilst Is no(exhaus(ive,
<br /> .,M-_— in s��quentia!arder, ndr does It lndlcate whlch
<br /> combin�tions are necessAry to make thrs defermirrafion.
<br /> CPI'���1G1�1011
<br /> This form is to be cornpleted and attached#o the Summary Fnrm of the Nlinneso�a Paliutian Control Agei�cy's(MPCA) Cam:pliancQ
<br /> lnspect3on Forin for�xlsting 5ubsul��c�Sewage Treatment System9. Ohservations, Interpretations,�nd cpnclusians must be
<br /> compleled by an inspeckor. Compte#Ed form must be s�ihmitted to the local unit�F gouernment within 15 days_
<br /> Property awner narne(s): ��-_ __��r-�l4�"�;:�,��
<br /> . — __... _.__
<br /> Pronerty�ddress: �p'1� C��jC��'�f.;�}�...,_G^(�'�.��_"�..�.�.�_C)��1-�_(� ,...
<br /> Prdperty owner's address{ir d�r�arent)�
<br /> Caunty: 1���'1�-�"�`�'���.,.w,,... Phone: °f�� � ��7"'�a � ���"'� -- .., ,_
<br /> 1�7���7y r,pJflfy fJTaf I JJEl50f1AJly l77AC�E fr1B 0�75('N�hdl15, rnier�)rc�t�ti�ns, and conr.11�sfans r�ported on ihfs Form end fhat they ar-e
<br /> rOl7P.rt.
<br /> �lame: _ �.-�J'�'�.� C�. �(f�;�'1a�.yy�,�"�� Certifir:Ation number: ���,'� _ �__
<br /> Btisiness licanse namP anc.i num�er: �.-'�_..'.:�'�'-''�-'�)_l1„�..�.._l_�1,C.,:.,...,'.,��;_�"����Jfa;,-_�'���-�-.�..l,cr(r— or
<br /> Name of local unit pf govern��2nt: �., _ _ _ �
<br /> Slgn�iure: �� -�,•'�' � �+�.��.... Date: � -��? �" (�
<br /> . ��� �--.--_...._
<br /> wq-wtvists4•39 Comp(i�nce Inspec�ion Form for�xisting SSTS
<br /> 4/1/OR
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