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07/30/2009 21:14 7634975011 SPTESTINGINC PAGE 04/09
<br /> Percel numbEr: . _ _ __ System slatus: �Com liant
<br /> , . . . _ ....._. ..__........ . . ..._._..,__ _.� P ❑ Noncom�llent '
<br /> , (a.a�leterminad by t/�/s formJ
<br /> Hydraulic Performance �nd Other Coinpliance - Compliance Inspection Form for Exlsting SSTS
<br /> Complrance Issue #1 of �
<br /> Dale of ob�orvallon: __7 _a��Dal , ., Reason For observation:
<br /> . 1�i�a��-���:���.„�.—.—
<br /> This form expirss upon next ins�eclfon or in lhree y e a r s,w h i c h e v e r o c c�r s Fl r s t: �
<br /> Compliahce ques#ionslcriterie: (R�qulred) Verification Method*: (pptianal)
<br /> _. (Check fhe apprapr/ate box)
<br /> - (Ghech the approprlafe bax) �
<br /> Dves the systPm dis�harge sewage to lhe � ❑Yes �No
<br /> �round surt�ce7 � Searohed for surface oullet 1�L� •
<br /> - —� _,.�.� _.,,�_,, .-
<br /> Does lhe system discharg�sewAge to drain 1 ❑Yes ❑ No � pertormed hydrt�ulic tesl
<br /> �tile` or surf�ee wetere7 � _ � Saarch�d for seeping in yarcl 1yc�
<br /> Dve�the system cause sewage bacicup � ❑ Yes I�No� Cl Cheeked for backup in home
<br /> into dwelpng or e�lablishrnent? .._���,� •
<br /> � Excessive ponding in soll system/D•boxes 1�
<br /> Do other slluations exist that hava the � ❑ Yes
<br /> potential to immediataly and adver�ely '� N� ❑ Woineowner testimony
<br /> impact or threaten public health or safety [] Qxamin�d for su�ging in tank
<br /> electr(cal,unsafe covers,etc,)?
<br /> Any"yes"answer lndtc�tes th�t the system!s an lmmfnent � "Black soil"2bove svil dispersal syslem hj�
<br /> U�reat to public health and safety. O 5ystem requlres"emergenCy"pumping
<br /> �• (� Performed•dye te�t
<br /> Does Ih�system pcse a threat ta ground� [j Yes � No
<br /> waler For any condilions deemecJ non- � 0 Other: �pLy��p�,,, _`�`
<br /> ,.,nrot` �ctivc�as determined bY the Ins ector? I _ ��_�p,�_
<br /> "Yes"indfcAfes that the system!s fa!//ng to protec( �
<br /> ground watc�r. !f"yes", describe the condition noted: �'� -•�--�
<br /> � "No standard prolocol exisf5. This lisl is not oxhau.st/ve,
<br /> -` _ "'� °, ,�— in sequanti�l ader, nor does if lncllca�e which
<br /> __., _w�„ , l combinefions�re neCess�ry fo make fhis deferm►natlon.
<br /> Certification �
<br /> Thls form is lo be compl�ted and atlached to the Summary Form of lhe Mlnnesota Pollution Control Agency's(MPCA)Compliance
<br /> Inspectlon Form for Exisling Subsurface 5ewage tre�tment Systems.'Observatlons,interpretations,and conclu�ions must bs
<br /> cvmpleled by an inspeclor.Cornpleted form must be submitted'to the local unil oF gov�mment within 19 days.
<br /> Properly own�r name(s): ��/� ► y,��,i� y�,j , __-
<br /> . PropeRy address: �J�U IGla�7�.1.._,_N���.. - ��
<br /> Property owners address(If dlfferw,nl): ' •
<br /> Count . ��.��� c �^ � •
<br /> y' _��J_���1..1__._._ Property owner phone: ��.� � o�`d al ":t.��
<br /> I hereby certify Iha(I personally made the observallons, inferpr�efatians, and eonclu.aions repor1ed on fhis form and that th�y are
<br /> correct. -
<br /> Name: �{,���, .5 d������_ � . CertificeUon numbe� lo a��,�,
<br /> gu�iness licensa name and nurriber. _S�Q�{��1;,l��,�_,,,,,�,����jc,�„ ����,.y9 7„���^ or Y
<br /> Name of locel unit oF gavemment: .
<br />. 5ignature: �L� `V�r -�"" , � Dele:---.�'Q'9 „_ , �
<br /> wwuv:pca.stat�.mri.us� �•� 651-296-6300 • ' 800-657�Bfr�,; TfY 651•�82-533z or 000-657-3864 • Available in altemactve formac�
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