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FROM : 'YS PHONE N0. : 4422091 Oct. 03 2002 01:20PM P2 � E Z/25/02 Water/wastewater-ISTS4.31 Compliance Inspection Form for Existing Individual Sewage Treatment Systems Minnesota Pollution Control,Agency Campletion of rhis lorm fulfills the minimal requiremena of Minn. Stat § �T5.55(2001)�nd Minnesota A. ch. 7080(1999�. P►ease refer to�xal ordinances for other requirements or information,especially for compliance requirements for bedroom additions. e I: Date of Inspection:/O'3`0� Rea�son for inspection: m��/�iv� propetty Owner(s) � i O Telephone� � Pee�on reguesting inspection o�Ai�'! Telephone( ) 5ite Address � �'� ��'1 �r A G� City��011,,I� Zip Code-��5� Fire No./Parcel No. Caunty �.rl� Township Legal Description t.ocai Regulatory Authority Date system constructed � System in Shoreland Area: ye no S�rstem in Welihead Probection Area: yes�Sys�tem serving a MDH licensed faality: ye�o .ocal Permit# (if any) S�stems built prior fi�April 1, 1996 and not located in Systems located in Shoreland or Wellhead Protection Shoreland or Wellhead Protection Area or Serving a Food, Areas or Serving a Food, Beverage or Lodging Beverage or lodging Establishment Establishment, or systems Buift altet March 31 1996 Is e sv�tem an imminent thr�at to public health or I e s rr�an imminent threat to �ubiic health �(a yes ansrv�eris an ITPHSsy.st�m) or safetv� (a yes answer is an 1'TPHS system) -Dlscharge of sewage to the ground surFace? YES - Discharge of sewage to the ground surface? YES NO -Disd�arge oF sevvage to drairitile or surFace wdters? YES -Dfscharge of sewage ta draintile or surFace waters?YES NO -Sewage backup irrto dwelling? YES � N -Sewage backup into dwelli�g? YES NO -Sftuation with the poterrtial to lmmediately and -5ituation with the potienbal to immediately and adversely impact or threaten public health or adversely impact o�threaten public heatth or sdFet� YES safety? YES NO Is the s�►5tem failinc�?(a yes answer is a fai/ing system) 2s the svstem failing'� (a yes answer is a fai/ing system) -Less than 7'INC feet of verNcal separatfon beiween -Less than THREE feet of vertical separation between � system bottom and saturated soil or bedrock? YES system bottom and saturated soil or bedreck? YES NO -A seepage pit,cesspool,drywell,or leaching ptt? YES -A seepage pit,cesspool,drywell, er leaching ptt? YES NO Is the sy�m,�on-compliant? Ys the svstem_non-compl��nt? - Is the system regulated under a monitoring plan or (� - Is the system regulated under a monitoring plan or operating pe�mit? (if no,go to page 2) YES• operating permit? ('rf no, go to page 2) 'YES NO If yes, If yes, -Has ihe required monitoring taken place? - Has the required monitoring taken place? YES NO (!f no, �e system is non-complying) (If no, the system is non-complying) -Does the monitoring indicate that the system msets -Does the monitaring indicate that the sysiem meets performance expectations? —performance expectations? YES NO (Il no, the system is non�omplying) (If no, the system is non-comp/ying) Page 1 of 2 wq-wwists4.31 .