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' f Husry C�Ison's <br /> Soil and Pe�olation Testlnc <br />� /�� Minnesota Pollution Control Agency (MPCA) 11�j RNe�^°W Rd. NE� <br /> � Hanover, MN 55341 <br /> Inspection Form for Existing Septic Systems <br /> �ATE OF 1NSPECTION: I S `j TIME: I�/iU PM WEATHER COND[TIONS: CIeA 12 1STS PERMI7�NUMBER: a'�8"33 <br /> BEASON FOR INSPECTION 1DENTIFICATION <br /> O Bcdroom or bathroo�t�d��,��::t,�`4, Property Owner(s) S H�Rtv���v �'Rv sT � Telephone O(�(c7- ���y <br /> ��var�ar,« Site Address 19os He-c'�T7}t1G l�R. C►ty ORon�O <br /> OComplaint ��� ? g �gq7 Z'lp COdC COunty HE�VNEP�rV � <br /> p�Property Transfer Fire No. Township Name <br /> O Othcr , ,; ;�;_ ;;'r; �;�j���: Is system opened up' Y N Full Partial Contractor/Lnstaller namc: <br /> Ha�k�(s)ever been pumped? � N Ycar System Builh 1 g� � <br /> If Ycs,how oftcn? �t-3-9U For what reason: �routincly Q baccmcnt backupfl sluggish plumbing Qothcr <br /> Any rcpair donc on systcm? Y What Whcn By whom <br /> Usaee: rJ othcr establishmcnt�dwelling O scasonal O other No.Bedrooms�_ No. of occupanu�_ <br /> Wntcr using appliances:�Clothes wazher�Dishwasher�Gatbage disposal OWhirlpool bath�Water conditioning unit OSclf-cicaning humidifier in fumacc <br /> Ncares�Surface Water: -�ft from which type of surface water O river O�eke O stream�other wt T LA�v D <br /> (Chcck appropriatc scwcr systcm componcnt and indicatc location on site sketch on back of form). <br /> Tank(,51: Tank(s)Material: Soil Treatment System: Other: <br /> _Scptic tank Fiberglass _rock trench _alternative system (idcntify rype) <br /> Acrobic tank Plastic _gravellcss trench _expericr,ental systcm (identify typc) <br /> Pump tank Metal chambcr trcnch _other(identify type) <br /> _Hofding tank Concrcte ,x sccpagc bcd <br /> Othcr mound <br /> _at-grade <br /> Tank(s)Size: A('PROX IUl.Y� ¢als Soil treatment area size(s):�1PPRoT U� sq.f� <br /> �OMPL.IANCE INSPECTION• <br /> 1�there or hac there ever becn am evidence of• g�� �jII <br /> Dischargc of scwage to thc ground surface? YES �NQ� <br /> Dischargc of scwagc to a surfact watcr? YES �10� <br /> A secpagc pit,drywcll,cesspool or leaching pit? ES NO F,�sT Tl��k N as NU C3o"?T�n� <br /> Lcss than thrce feet cf vcrtical scparation betwcen thesoil treatmcnt system <br /> bottom and saturated soil or bcdrock? YES <br /> Scwagc backup into dwclling or other establishment presently occurring? YES NO <br /> Situations with thc potcntial to immediatcly and advcrsely impact or threatzn � <br /> public health or safety? ES NO Np� CeSS Poo L <br /> • if YES was znswcrcd for any of the above Guest:ons,thc s;sttm is fai!ing according to Mian.R.ch. ?Q$0.0060. <br /> (if wcll sctbacks are violated,a potential imminent threat to public health or safety may exist) <br /> ST.4TUS OF THE SYSTF.M <br /> Based on the compliance inspection conducted above the system status is �111 L�N l� ,therefore, <br /> (Choose: in compliancc OR failing ) <br /> this document is a _ nIUT�CE C7f No�J UM PL�r�NCE <br /> (Choose:Ccrtificatc of Compliance OR Notice of Noncompliance ) <br /> CERTIFICATION <br /> I hereby cenify as a state of Minnesota licensed lnspector,Designer I or Qualified Employee that my observations recorded on this form are accurate <br /> as of the date at the top of this form for the site stated above. No determination of future hydraulic performanc�can bc made duc to unknown <br /> nditions auring systcm construction,future watcr usage over ihe life of the systern,abuse of the system,and/or inadcquate maintcnan=e all of <br /> nich will adocrsely affcct thc life of the system. <br /> Inspcc:tor's name S� }� T OISON Phone No. `'�q$'-£{7�� Lictnse and/or Regisuation Number g I v <br /> p ease Fnnt — <br /> Inspcctor's signaturc � i ,_ --- ---_ - — -------- patc _ 7�a�/�j 1 _ <br />