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<br /> � Minnesota Pollutian Control Agency(MPCA) n
<br /> �� Inspection Form for Existing Septic Systems N� 0 3 1998 .
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<br /> �p�,T�OF INSPE I01': D � 'I'iME: Z��O .ril. WEATFIER CONDITIONS; s WJN I T P�.R
<br /> RLAS�N F�R 13�SPF _� I[ZE1�T�F�CATION '/
<br /> O Bedroom addition � � Property Owner(s) S'T� L S�t�v � Telep6on (af7,1�t�i(o-L�l�Q
<br /> O variaau ' Site Address J��S�o�J . S City �4
<br /> OCornplaint Zip Code SS3S�o Coanty ,t/ �/
<br /> �Properry Transfer (buyer or se�ler) Fire No. �ownshlp Name
<br /> ()Other ? Is system opened up? Y FufE Partlal Contractor/installer name £T O �—
<br /> Area with locel ordinance N • Township Itanee Section ' Quartera
<br /> .. ..:�li(I�I . � .. ..II'i .f..i r'�14� I t �i u " �. I�i��y-�n �I �g �. � �I �-:r��� �'N'� � ��iftl i I p�� �4 �I.��Id� �.
<br /> ;�i I� �_l� CI �, � I-i.t 1., p i I' ^ h IP� li �G j: I t � I . i li R �+ :1 Ilii I II �� � �.:I I
<br /> svsr�M > � I i f ,y I 4 I f �� I II I i 1 � I I��� � I
<br /> Has tank(s}e�er beea um d' �y �i�T ���I'',I'�r Year Syst�em Bmlt: � i��_ � � ,,�� �� , � ' ` .;�u ���Y �'�' � ' �4'� '! I���k,�'��'�
<br /> l f Y e s,h o w o ft e a.� . F o i w h a i'r e a s o n �a u tm e ly p,basemen t b c kup�s lugg�s h p lum b ing (7 o�et � ''�,;. `!� 's�1 ��
<br /> Any npair done oti sysiem:, N What 'EiiJ'. TA��„t!k'S � When ; ,� a1 � ' �' �ywhom." � - i ��,� ..'Q,1 ��� ;
<br /> IJsage: O other estsblishmen��$(dwelltng O seasonal.O other_ �'� _ � °"�•�� ' �` ��4 ,No�Bedrooms ��N 'of occupanCs' ':' _
<br /> Water usiag appliances:�I�l thes waslie�;�,pishwasher p Garbage djsposal OWhi5lpoot bath O Water condihomn�umt OSelf cleani�g hurr�td�fier�n fumace '
<br /> tieares:Sarface��a.er: ��ft �rom vrhich type oi aurface water u nver.j$lakep streamp qther "' ' `
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<br /> .. ... .�::. . � �� ��� .�., ,:��::.�i�. ..' . :: • ,..:::. , .,:'� i;I'. - i
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<br /> . . ..:.. ..... . . ..�. .. �:
<br /> (Check appropriate sewer sy tem componcnt and indicate location on site sketch on back of form).
<br /> Tnnk lsl; Tank(�l Material: Spi�T_,feg�ment S,sv tem: Otfier;
<br /> �+ �Septic tank Fiberglass �rock treach altemative system (identify type)
<br /> Aerobic tank Plastic _gravelless trench �experimental system (identify type
<br /> Pump tank Metal _chambar trcnch �,other{identify type)
<br /> Holding tank � Concrete �seepage bed
<br /> `Other �Other �rnound �p
<br /> a� —at-grade `��.� G j3'� 1e�fAl�.D
<br /> Tank(s)Siu: DO• dIs Soil treatment area sixe(s): DO sq,fc, Depth of system botiom[rom grade: ? \Vei!Set ack: !b .
<br /> C0�1jp�,,7ANCE iNSPE��T�,ON" `
<br /> Is thece or has th v I I ,:�Q
<br /> Discharge of sewage to the round surface ' YE$'' NO_' p� '
<br /> ' , .+�.- t0 d-' �S,
<br /> Discharge of sewage to a su face wat�r? ' YES
<br /> A seepage plt,'drywoll.cess ool or lea'ching pit? ', ' YES : ' C T ; ; Go, �
<br /> Less than three.feet of verti l s�paration behveen the soil treatment system �
<br /> bottom end saturated soil or edrock? YE NO /116 �/�f �
<br /> _ .
<br /> Sewage backup into dwellin�or:other estabtishment presently occurr�ng7 • ' YES �N,Q� �
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<br /> Situations�vith the pote�tial�fl immediately and ad�-ersdy irnpact or threaten
<br /> pnhlic health or safety? YES NO
<br /> *i�YES was answered fo:a�y ui tha abovt queszions,the system is iailing according to Niinn.R.ch.7080.�bnt�.
<br /> (if well setbacks are violated a potentiat imminent threat to pub[ic health or safety may exist)
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<br /> : ' ' .; , �; I�t II t�I l II. I I;-i il �I y
<br /> Based on the compliance in pect�oa condacted above the systetn status�s � , �;����. � �Rh�erefore,
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<br /> �' , ��'+ i . � '
<br /> ' . . '��u, ; ; ' y� (� (Cho /se� �n com�La�cp OR faillpg OR failt{�g/i mtncntthreat)
<br /> thi�documcnt is s • �d � ��� ��'��' /fr� ���/ �f���C:v� h I II ! ` ' ' �h i ilPi�1 ri 1i41��1;i � �i!q"'���liii ll
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<br /> (Choo e Certrficafe of Compl�ance.OR Notige af�Ioncompliance,�� ;;� � '� 6 Ir31 I I�L41u� I��� ' '�I �I{��� ��
<br /> .' .,:I' ' �i .' �r �i:r�::. �11PI�1"ali .k�•I�. � , :fi � S nt�:"� � ��� i•��� 'f ,P:' .�n.-1:i,1 � � 6- ���iIr�HIF�i1 �- I�.��,I��flpliii�i
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<br /> C' . 1'iFIGATION ' I
<br /> t hereby certify as a state of innesota licensed Inspector,Designor I or Qua[ifsed Employee that my observations reeorded on is fotm are accurate
<br /> as of the date at the top of ihi form for the site stated abovo. I hereby certify that a!E inspoction work was completed according o applicabie
<br /> requirements. No dcterminati n of future hydranlic performance can be made due to unkno�vn conditions during system constr ction,future water
<br /> usage over the life of the syst m,abuse of the system,and/or inadequate mairttenance all of which will adversely affect the life f the syStem.
<br /> Inspector's name /�/I�E (print} Phone No� 0 �u License and/or Registration lv'umber 3 t�.
<br /> Address 't s' ���
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<br /> . Signatur� Date D
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