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01/31/2012 14:31 9528733112 PAGE 64/06 <br /> ,� <br /> Pa�cel number: _ System status; Compliant ❑ Noncompllant <br /> (ss datermine y t rs fo►'mJ <br /> Hydrauilc Performance and Other Comp�iance <br /> Compliance Issue 1 of � � <br /> Date of obse►vation: � ��' Reason for observaGon: �° /c!� <br /> This form expires upon next inspection or in three years,whichever occurs first: _. .___________ <br /> Compliance questionslcriteria: (Required) VerifiCatfon Method*: (Optional) <br /> Check the a ro rJate box (Check the approprlsfe box) <br /> Ooes the system discharge sewage to the r] Yes No �Searched for surFace outlet <br /> �round surtace? <br /> � PerFormed hydraulic test <br /> Does the system discharge sewage to drain ❑ Yes No <br /> tile or surface waters? �Searched for seeping in yard <br /> [ <br /> Does the system cause sewage backup ❑Yes NQ ❑ Checked for backup in home <br /> into dw�llin or establishment? <br /> � Excessive ponding in soil system/p-baxes <br /> Do other situations exist that have the . []Yes No <br /> potentlal to immediately and adversely ❑ Homeowner testimony <br /> impact o�threaten publlc health or safely ❑ Examined For surging i�tank <br /> electrical unsafe covers etc. 7 <br /> ❑ "Black soil"above soil dispersal system <br /> Any"yes"answer ind/cai�s that the sysiem Is an lmmfneni <br /> threat to publlc healeh and safety. ❑ System requires"emergency' pumping <br /> -- ❑ Performed dye test <br /> Does the system pose a threat oo ground ❑Yes No � pther. <br /> water for any conditions deemed non• ----�--- � � � -- - �� <br /> „protective as determined by the ins ectnr? _ _ _ <br /> "Yes"indicates that the 5ystem is fafling tp protecf _�___ <br /> ground water. If"yes'; describe the condFt/on nofed: <br /> 'No standard protocol exists. This 11st is not exhausfrve, <br /> in sequential order, nor does rt indicate whieh <br /> Combinations are necessary to make this deferminafion. <br /> Certification <br /> This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agen�y's(MPCA)Compliance <br /> Inspection Form for Existing Subsurtace Sewage Treatment Systems. Observations, interpretations, and conclusions must be <br /> completed by an inspector, Co pleted form rnu be submitted to the local unit of government within 1�days. <br /> Property owner name(s): � J (��} __�__.__—.—...._....... <br /> T�,._... <br /> Property address; � �7 � _ , _�__ ____, <br /> Property owner' address(li different): <br /> � <br /> County: Phone: ,__„�,_ __^__ <br /> 1 her�by certify thaf!personaUy made the obscrvations, inte�pretatians, and conclusions reported on this form and fhai they are <br /> correct, <br /> Name: , y�._„ti��1Ll(�� — Certiflcation number: ��_-----------._.. <br /> Business license name and number. ���_.�Q,��,'��(�t �Y1L,,^a�Vo� ._._^.__ or <br /> Name of local uni o�er ent: <br /> Signature; _... .�_...__ Date: , � .�� 1.,�.... .. . . . <br /> wq-wwisrs4•31 CompliQn�e lnspectfon Form/`or ExisCPng SSTS <br />