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i , �, � . . ; �Parcel number. . System status: ❑Compliant �Noncompliant I (as dete�t3i}ned by this fonn) I Hydraulic Performance and Other Complian�e Compliance issue #1 of 4 � Date of observatEon: �-} �-p� Reason for observatiqn: This form expires upon next inspection or in three years,whichev�r occurs first. Compliance questions/criteria: (Required) Check the a riate box � Verification Method*: (Optional) Does the system dis�arge sewage to the ' «�k�e aAPmp/��te box) round surface? ❑Yes [�No ❑ Searched for surtace outlet Does the system discharge sewage to drain ! ❑ Performed hydraulic test tile or surtace waters? ❑Yes ❑No? i Does the system cause sewage backup i � Searched for seeping in yard� into dwellin or establishment? ❑Yes �No , ❑ Checked for backup in home Do other situations exist that have the � � ��331Ve ❑Yes �No I �d�9��soi1 sYstem/D-boxes y.1� potential to immediately and adversely , ❑ Homeowner testimony impact or threaten public health or safety � eledrical unsafe covers etc. ? � ❑ �mined for surging in tank a�Y"Yes"answer Indicates that the systar�is an imm/nent ! � �B�ack soil"�b�ve soil dispersal system j.1,a. threat to pub/Ic hea/th and safety. � � ❑ System require$~emergency"pumping Does the system pose a threat to ground � Pe��ed dYe test water for any conditions deemed no�- Q Yes �No I rotective as determined b the ins ectoi'? i ❑ Other. I • "Yes"indicafes f/�af the system is failfng to protect , • ground water.If"yes';describe the condit�on noted: ' i "No standard protocol exists. This list is not exhaustive, in sequential oMer,nor does ft indicate which . � combinations are necessary to make this deteitni�ta6on, Certification I This form is to be completed and attached to the Summary Form of t�e Minnesota Pollution Control Agen 's MP inspectlon Form for Existing Subsurtace Sewage Treatment Sy tems.Observations,interpretations,and conclusions must be completed by an inspector.Completed form must be submitted to th�locai unit of goveYnment within 15 d ys ( CA)Compliance Property owner name(s): � �o j � Property address: ��,(r,� '�-}OLt..-�9.,��p �, Property owners address(if different): � County: �-��{�� Phone: `7,�� --l--1 t�,q ,.. �r b'9(�, I hereby certify thaf/personally made fhe obse�vaBons,inteipretations, and conrlusyons reported on this forrn and that fhey ane correct. I Name: �� ,�! � �� { �g�' �L'�� I Certiflcatlon number. f�;a� Business license name and number: $- - _ � 1�''�l�[1. »�� lU �� -z Name of local unit of govemment: �'�'� � � K 1^� or ,�, � , I Signature: � jl;r, ,.��(`- , _._._.,_,.,.�. Date: � - a ) I ( - _� � � w9-►a'wists4-31 4/f/o8 � Compliance Inspection Form for fxistins SSTS ; ._�___.._.___. ___.__---.-__._____..__�__�____�._.______ I