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10/24/2008 02:35 7634975611 SPTESTINGINC PAGE 04/09 <br /> , � <br /> I <br /> I <br /> � <br /> I <br /> Far�cel numbe� � . System status: �Compliant ❑Noncompliant <br /> � " I (as determined by this form). <br /> ance and Othek Com Ilance' <br /> Mydrr�ulic Pertornt P <br /> Compl9ance Issue #1 of 4 <br /> pete of observatidn: 1 r�-�-0'4�_ Reason fvr observation: ���iR�"� �r4�'���� _.,,^� <br /> 7h�s form expires upon ne�Insp�ction or in three ye�ers,whichever rs firsi: <br /> C�ompliance questionslcrlteria: (Ftequired) Verification Method*: (Optional) <br /> Check the�e ro r�ete box � � (Ch�eck the appropriale box) <br /> 4oes the system discharge sewage to the []Yes ■No 1 � Searched for sutface ouGei <br />_.ground surfece? I <br /> ❑ Performed hydraullc test <br /> Does the system discharge sewage to drain ❑Yes ❑ No <br /> tlle o�surface waters? � � Searched for seeping in yerd )sfl <br /> boes the system cause sewege backup ❑Yes �No [] Checiced for beckup in home <br /> inio dweflin or est�blishment9 _ � ■ Excessive ponding i�soi)system/D�boxes�.10 <br /> Do other s(tuations exist thAt ha�►e the �Yes �No � Momeowner testlmony <br /> potential tc immediately a�d adver�ely <br /> impact or ih�eaten public heaNh or safety ❑ Examined for surging in tank <br /> el�cWcsl,unsafe covers,etc.)4 _ � 'Black soil"above soil dispersal system N� <br /> Any"yes"answer indleates th�t the system is An imm/nent <br /> threat t+e publfc health and s�i�ly. . � System requlres"emargency'pumping <br />.� -., ❑ Performed dye iest <br /> Ooes the system pvse a threat to ground ❑Yes �;Na �] Other. <br /> water for any conditivns deemed non- I —,_ <br /> �rotect'n►e as determi�ed by the inspectorl _, _.,,,,_ <br /> "Yes"indicales tfi�t d�e system!s failing to prol+ect I � ,___„ <br /> ground water.If"yea'; descHd�tlte conditlon not+ed: <br /> . 'A!q sfandand protocol exists. This llst la not exheustiYe, <br /> ,,, In sequentlel order, nordoes Itlndicete which <br /> comGinetions�are necessery to mske this detem►inafion. <br /> Certificafiion � � � <br /> This fo�m is to be completed end attached lo the Summary Fortn of t e Minneso#a Pollutior�Control Agenc�s(MPCA)Coropliance <br /> InspecHun Form for Exlsting Subsucface Sewage Treatment Sys ms.ObsE�rvations,Interpretations,and cancluslons must be <br /> cvmploted by an Inspector.Cempleted form must be submltted to the local unit of povemment wilhin 15 days. <br /> property owner name(s): �jp � � - ��____.... <br /> Properly address: �b 7c7 I.�L1,�__<��e`, � 4�J .I �'�}� • <br /> Property owners address(if dlfferont): I <br /> County: ���.9,1t.^?�� __� ' Phone: � (v..—p�4S� <br /> I he�aby certii�r that 1 personally made Nie observstions,/n(erpnetatio , and concluslons reported on lhis fonn end thai they er� <br /> co►r.�ct <br /> . � <br /> Name• ����,i� . SL�:��%��„_,.,,,. � CeniflcaElon number: �ic��,7 W_,_^___ _ <br /> Business Iicense neme and number: S-�'�'�)f.l 1����3 � ` '7 3.�-y;y '�- ?�.,'�,�eif� or <br /> Name of local �il of govemment: , <br /> 5ignature: ��� 1, ��---------_---w i pate: /0 ��d�04� <br /> wq-wwisrs4-31 � Complidnce Inspection Form for Existing SSTS <br />