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12f16f2008 22:40 7634975011 SPTESTINGINC I PAGE 05/13 <br /> . I <br /> �a�cel number: System status: �Com Ilant <br /> —r—"�` --� �� p ❑Nonco pliant <br /> (as determined by thls fom1J <br /> � , <br /> Hyd�ulic N�erfm�nance and Othet Camplpance <br /> Compliance issue #1 of 4� <br /> Date of observatlon: �,�1,, �����_ Reason for observation; g�� � --( ,� <br /> 7his form explres upon n�xt inapectian or in three years,whichever occu�s flrst <br /> Compliance question�lcriteria: (Required) Veriflcation Method'�: (optional) ^ <br /> ^„ Check the�appiapri I�e boxJ � (Check the appropriate box) <br /> Does the system dischar�e sowage to the � ❑Yes �No <br /> �round surFac�? ❑ Searched for surface outlet <br /> Does the system discharge sewage to drsin ❑Yes �No Q Pe��ed hydraulic test <br /> U�e°�s-- urfac�waters� . � Searched for seepi�g 1n yard 1J0 <br /> �� <br /> Does the system cause s�we9e backup ❑Yes �No I] Checked i'or badcup in home <br /> i�to dwellin�or estabiish ent? <br /> - � Exc�ssive ponding In soil systam/D boxes 1Jo <br /> Oo o0�er situatfons exist tliat have tAe �]Yes �No <br /> potentlal to immedlately�md adversely C) Holneowne�tesiimony <br /> Impact or threaten publlc I�ealth or safety �] Examined for surging in tank <br /> (elecficai,unsafe covers,�tc.)? <br /> � "Black soil'above soll dispersa)sys em <br /> Any"yes"answerindfcat�s that tltm system fs an irt�minent� � <br /> d�rsat b publlc healtlt and sal9ety, [] Syetem requlres"emergency"nump�ng <br /> -' - � PerFormed dye test I <br /> Does the syst�m pose a th�eat to ground 0 Yes �No <br /> water fa�eny conditlons de�med non- ❑ Other. <br />.,proteotive as determined b�the Inspecto�? µ._ _` ^�_ �"r— <br /> "Yes"indicales fhat the�ystem is failMg M�r+�tect ' � <br /> ground wefer.If"yes",d�scriUe the condition noted: ••� �—��.- <br /> 'No standeM p�toco!exJsts. This list is n t axh�usHve, <br /> - � � in seque�Nal on9er,nor does It Indlcate w !ch <br /> � w cembinations are necess�ry to make fhls etennination. <br /> Certifica�ion <br /> This form is to be complete� and attached to the Summary Form of the Minnesota pollulion ConVol qgency's(MPCA)Compliance <br /> Insp�ction Fonn far Exist�ng Subsurface Se�nrage Treatment Systems.Observatlons, Interpretations,and condus�ons must be <br /> completed by an inspector. �ompleted form must be submitted to the local unit af govemment v�ithin 15 days. <br /> Property owner name(s): �l�w, � �W�,. V10+�5� I <br /> Properly address; '� I�,'�, ��+M,�'is-(Ow,J '�o✓� ,C�O1•L� �_ <br /> Property owner's eddress(�f�diKerenq: � � <br /> County: -�,�.�S,�r,�y , _....,._, ,„,� Phone: °1_a�Z-4v'�l -U�. <br /> I her� � � <br /> by certrly lhat 1 person�lly mede fhe obsenrallons, interpr�eta6ons, end conciusions neporfied on this fiorm and fha�they A��e <br /> COlr.�cf. ! <br /> Name: �J��. SLI.���ti�A���e, .` Cenlflca�on number. �o�'� II <br /> Business Ilcense name and number: �-'1� '�i4�)_,�,�__���','��j� ' �����c� q_ � � or <br /> Name of local unit of goaemdnerrt: I�� <br /> Signature: ,.�_. �� � �'�"'�-- � Date: ���.../�..�..L? <br /> �-�.�.` <br /> � I <br /> wq-wwisrs4-31 Compllance Inspection Form for E�isting SSTS <br /> dl�inR <br />