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�vilnnesota Potlution Control Agency (MPCA) <br /> ' `' • � Inspection Form for Existing Septic SysCems <br /> D.�TE OF I\SP'ECT10�: 1-1 D-�15� '[�g; I'I 3 L� WEATHER CONDITIONS:_L�-c7�.�'bs-1 ISTS PERMIT NUMBER: <br /> �'�SO�FOR L\SPECTiON ID�TIFiCATIO\ <br /> �>�eacoa:,a b�mr�oom x:aiuon Property Owner{s)_M AR� �sC�J�...l so�..1• Telephone(wa� u n y -o 3��, <br /> �;v,t;,a,x Sjte Address�o� 1-1 o�..L'i���_ '�o�i� City_�o�.c o <br /> c;co�;ru ZIp Code County �.�-��-�ca�aD• <br /> �s�o�T� Fue No. Township Name <br /> (>Oc1�a Is s7stem opened up' Y g Full Partia! <br /> �s)erer been pem ' �7v :� Ynr S+stem Bafl� ��l`d'7 <br /> If Yes,bo+�oftm'€�� K�� For w+�ac reasod�casinely 0 basemau backup0 slu�ish plumbtnt0 ochec <br /> ,1ay repsir done oa system? Y � w3at When By whom <br /> Ua=e: 0 aha es�abtishnent�ds�elliny0 seasoeaD otha No.Bedrooms No. of occupants._,,,�,_ <br /> Kater usin;spp8anees: �:l,othes washa ODishs�asixr OC�arbnte dsposal O Whirlpool bath�Wata tonditionin=unit O Self-clanint humidiliv in Aunace Nearest <br /> Sorfaee t�'ater. _ — R'hom whic5 type o[sarfioe r�tn O riveD laka0 strran0 ocher <br /> (Clxck ap�ropriau sewa system component sad indicate location on site sketch on back of focm). <br /> • Tank fsl: Tank(sl�faterbl: So�Treatrnent Svstem: Other. <br /> �[Septic cank _Fibecglass - ,�[rock trench _alternadve system (identify type) <br /> _Aerobic tank _Plasdc _giaveqess trench _experimental system (identify rype) <br /> _Pump tank Maal _chamber�ench _other(idenrify type) <br /> _Hoiding tank �[Coocrete _seepage bed <br /> _Odur _mound <br /> _at-grade <br /> Taar(s)Sise: a -I DDO gals Soil trnement uea stu(s): 1 a.D D sq.R �Li"t�'R�''��05 <br /> 'P}i vri? G N�1'IN'E+GR- 1—lO 0 O �+v�I. <br /> CO�iPLIANCE INSPECTION• <br /> 1s therc or has�here e�•er been anv evidence o� � $�Qp�,� �D <br /> Discharge of sewage to the ground surface? YES � <br /> Discharge of sevvage to a surfaee water? YES � <br /> A seepage�t�grywelt,caspool or leaching pit? YES NO 7 9.�� -tp -g�. 'p N rn-p�q-�._-�. <br />„ Less than e feet of�•ertical separation betovan the soil tteatment system S3�1 �tic.�m� <br /> boaom and saturaced soil or bedrock? o�C o� sNo��a q-�qS � Np �.S � mo-�� so�L <br /> Sew•age backup inco dw•elling or other establishment? YES ,� <br /> Simations with the po�ential to immediately and adversely impact o�threaten <br /> public health oc safety? YES � 1 �{�S � ► ��ff4�-t�L �5 9..1oT <br /> w .�u N.� <br /> •if YES was answered for any of the above ouesdons,the system is failing according to Minn.R.ch.7080.0060. <br /> SfATUS OF THE SYSTEM . <br /> Based on the compliaace'inspecdon conducted above the system status is '�141 L)�t� .therefore, ;,�r. <br /> (Choose: in compliance OR. failing ) <br /> this document is a i�lfl�11.�E- O'�9.byLGDwtF1�1�l�C <br /> (Choose:Cercitcate of Compliance OR Notice of Noncompliance ) <br /> CERTIFICATION <br /> [hereby certify as a state of Minnesota licensed Inspector,Designer I or Qualified Employee that my observations recocded on this form are <br /> accurate as of the date at the top of this form for the site stated above. No determination of futu�e hydraulic performance can be made due to <br /> unknown conditions during system constrvction,future water usage over the life of the system.abuse of the system,and/or inadequate <br /> maintenance all of which will adversely affect the tife of the system. <br /> ��a <br /> Inspeccor's name �-✓Cf.l�.1 Q, sl.1�Y�tn��v'P,�'� Phone No. �1�i7 3S(ele License and/or Regisvation Number 3R y <br /> (please print) <br /> Inspector's signaturc �� �- �� Date a . -1 S-9.S� <br />