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� I . <br /> 2/25/02 � Water/Wastewater-ISTS4.31 <br /> Co.mpt�iance Inspection Form for Existing . <br /> ' � Individual Sewage Treatment Systems Minnesota Potlution <br /> �. Controi Agency <br /> Completlon of th/s form fulflll�fhe m/nlmal requirements of Mlnn. Siai:§ 11b.55(2D07)end Mfnnesofe R. ch. 7080(1999�. Please refer <br /> to local ordtnances for other requtrements.or informatton.espectaliy for.complfance requirements for bedroom addittons. <br /> G '� � <br /> Date of Inspectlon: ~�� �- ��`� Reason for tnspectton: ._ � � � � ` <br /> ProperLy Owner(s) � - Telephone ( ) <br /> Person requestin �In"s ection '%t � �?'� ,''> `�', '__,'�- � • ' � Tele hone �, `y ' '� <br /> 9 P p �� ; )�� <br /> Site Address ; `� .� ' ,�;' -.�-:' ; ` ? �, �Clty ._����: � � ZIp Code <br /> Fire No./ Parcel No. � � Co.unty 1-� '`�' ';`� 1 ''�. Township <br /> Legal Descriptlon <br /> Local Regulatory Authority :- �,���.�° ° � <br /> Date system constructed %° - -' ' ' System in Shoreland Area: yes �no? System in Wellhead <br /> Protection Area: yes;no' System serving a MpH licensed facility: yes ;no,`Local Permit# (if any) <br /> Systems built prior.to APt�tl i, 1996 and not located in Systems located in Shoreland;or Wellhead Protection <br /> Shoreland or Wellhead Protectfon�Area or Serving a�Food, Areas or SeNing.a Food,Beverage or Lodging <br /> Beverage or Lodging Estab(ishment Establishment, or systems Butit after <br /> March 31 1996 <br /> �,s the svstem an imminent threat to cubilc health or Is the svstem an tmrt�Inent threat to aublic health <br /> safe (a yes answerls an IFPHSsysfem) � or safetwP (a yes answer/s an I7PHS.rystem) <br /> -Dlscharge of sewage to the ground surface? YES NO -Discharge of sewage to the ground surface7 YES NO ' <br /> - Discharge of sewage to dralntfle or surtace waters? YES N0 -Discha�rge of sewage to dralnttle or surface waters?YES �NQ <br /> -Sewage backup Into dwelltng? -YES NO -Sewage backup tnto clwelfing? YES NO <br /> -Situatton wfth the potenttal fo immed(ately and -Situatton wIth the potentlal to immedfately and <br /> adversely fmpact or threaten publlc health or adversely impact or threaten public health or <br /> safety7 . YES NO safety? YES N0 <br /> Is the svstem failina? (a.,yes answerls a fa!/ingsystemJ �s the svstem'failina? (a yes answe�/s a fa//ing system) <br /> -Less than'iW0 feet of ve(t(cal.separat(on betw�en� , -Less than�TFtREE feet of vecttca)separation between <br /> system-bottom and sattarated soil ortiedrock? � Y�S dV0 system bottom arid saturated so11 or bedrock? �YES? NO <br /> -A seepage pit,cesspool,drywell,or�leachfng pIt? YES �NO -A seepage pit,cesspool,dryweli, or leaching pit? ;' YES NO <br /> Is the svstem non-comnllant? � � �s the svstem�non-comnliant? <br /> - Is.the system regulated<under a monitoring plan or • -` Is the §ystem�regula#ed under a .monitoring pian or, <br /> operating peRnit? (lf no,.go to page 2) YES NO � operating permit? (If no,go fo page 2) YES No ' <br /> If yes, . . - If yes, <br /> - Has the required monitoring taken place? YES NO -Has the requlred monitoring taken place? � YES NO <br /> (lf no, fhe system/s non-complying) (if no,the sysfem!s non=complying) <br /> - Does.the monitorfng indfcate that the system meets � �-Does�th�e,monitoring indicate�that the system meets <br /> perForman�ce expectations?; � � '�`YE5 .NO �� � �' , perfotmarlce e.xpectations? , . YES No <br /> (lfno, thesysfem is non-compiying) � ' � � � (if no, ihe sysfem7s non-cvmplying) <br /> ,,.�, . <br /> Page 1 of 2 �" wq-wwists4.31 <br />