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07/28/2008 01:26 7634975011 SPTESTINGINC PAGE 03/05 <br /> � <br /> Parcel numher: , .� System status: []Compllarrt �Noncompliant <br /> (es detemuned by this formJ <br /> Hydraulic Pert�r�nance a�d Othe� Cornp�lance <br /> Complia�ce Issue #1 of�4 � <br /> Date of obsenr�tlon: ��-) �,.-0�6 Reeaon for observatton: �yh�� . • <br /> This form expires upon next inspection or In three year3,whichever occurs firsi: <br /> Compllance questians/criteria: (Required) Verificatlon Method�; (OpiionaQ <br /> _�Check the. pp'p/n �ete box _ , • (ChQck�he epprop�ato box) <br /> Do�s the system discha�ge sewage to the ❑Yes �No <br /> �round surFace? ❑ Searched for surFace oullet <br /> Doea lhe system discharge sewage to drain ❑Yes []No? � Pe�O��d hydreulic teat <br /> tile or surtace watere? • � Searchecl for seeping In yard 1�'1i <br /> Does the systorn ceuse sewage badcup [�Yes �Na ❑ Checked for backup i�home <br /> Into dwelling or ostablishment? <br /> �-�— �. Exceasiva ponding in soil system/D-boxes y►t� <br /> Do othel'situations e�rist th�t h�ve the �]Yes �No <br /> potential to Immediabely and adver�ely ❑ Homeowr�e�testimany <br /> impact or threaten public health or safety ❑ �xamined fo�surg�ng in tank <br /> electrical, unsafe covers etc.)? � <br /> Any"yes"answer fndlcates that the sysi�mm is an lmm/nent � "�facic soll"�bove soil dlsparsal system �.1J, <br /> d�reat to pub/!c health and sAftlty. ❑ System 1'equires°emergency"pumping <br /> boes the system pose a threat to grbund ❑Yes �No p pe�O�ed dye test <br /> weter for any condltlons deemed non- ❑ Other. <br /> rotective as determined b the ins ectoi'? ' � <br /> "Yes"indicates that th�system is fa!ling to protect � � <br /> ground wat�er.Jf"yes; describ�tlle condition noted: —, „ <br />^ _ 'No standarol protoco/exists. Thls list is not exhausNvca, <br /> - � in sequential order,nor doas it indicate which <br /> . , combinetlons are neaessery to make tltis determination, <br /> Certificat9on <br /> This form is tv be completed and att�ched to tHe Summary Form of the Mlnnesota Pollutlon Control Agency's(MPCA)Compliance <br /> InspectJon Form fur�xlsting Subsurfa�e Sewage Treabnent Systema.Observatians, Interpretatlons,and conclusions must be <br /> completed by an inspector.Compl�ted form must be submitted to the Iocal unit af govemment wiihin 15 deys. <br /> Property owner name(s): pp <br /> Property sddress: �`�Ips '�OLLYk�.S► p, �� <br /> --� <br /> Property owner's address p►dl�'erenq: <br /> County: �:�9�►�1.� , , , Phone: �J�ol --�,IJt <br /> �j' � `d b�,�_ <br /> 1 heroby certify tliat I psrsonalfy made the obsenre�ans,interpietedons, and conCluslons r+aported on this fom�end thaf they are <br /> correct, <br /> Name; <br /> -������43�1.��_„_,,, Certificatlon�number: _��,7 <br /> 6uslness Ilcense name and number; S-�Q' •�a-�).�� ��,�,�����^�� �� ��.�y or <br /> Name of tocal unit��of govemment: _ ^ <br /> , <br /> Signature: ��— , (,,��.� "���'- <br /> -- -�. .,._ Date: !) - a 1 �(� <br /> wq-wwists4-31 � Compliance Inspection Form for�x;st�inQ S57"S <br />�J11/08 <br />