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64/27/2010 21:26 7634975011 SPTESTINGINC PAGE 05/09
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<br /> �'arcEl number: ._ .. .. __, _„_,,,,, ,..,,, , _..,._„_,. .,,,__.__._ 5ystem st2lus: � Compliant ❑ Noncompliant ' �
<br /> (as delermined by Ihis form) �
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<br /> Hydraulie Performa�nce and Oxher Compliance — Compliance Inspeciion Form for Existing SSTS
<br /> Complian�e Issue #1 of 4 '
<br /> Date of observallon: �_�'�-,ap,�p Re�son for observetlon: '��t-��i��(. �(Q'�Ar�.1.�, � �
<br /> Thls form expires upon nExt inspectlon or In threa years,whicliever occ�as flrst; , �__,..^ .,�_._J
<br /> Compliance questionslcriteria: (R�quired) Verification Method': (pptlonal) .
<br /> (Chech the appropr�ato box)�„.,...___ (Cliecic the approprlate box) '
<br /> Does the system dlsaharge sewage to lhe � ❑Yes � No • '
<br /> � Se�rchc�d for SurFace oullel'�11�
<br /> ^,gruund surfece7 .__ __ � ,_�„ .�,_ ;
<br /> ' ❑ f��rformed hydraullc lesf
<br /> Do�s Ihe systEm discharge sewage to dl'eln � ❑Yos ❑ Nq • � ,
<br /> .,,1lle or surface wAters?, ,.,, � . � ■ Searched fo�seeping in yard 1.�0 .
<br /> �ves tl�e system cause sewagP backup � CI Yes �No� ❑ Checiced far backup in home .
<br /> into cJwelllnq or esleblishmenl7 � �
<br /> -----��--�•-- � Excesslve ponding in soil systemlD-boxes r,p
<br /> • �Do other situations exlsl Ihal have lhe �+0 Yes �'No ❑ Homeowner testimony �
<br /> rotentlal to Immecllately and adversely • �
<br /> impact or threaten public healtfi or s�fety ❑ Examined for Surging In tank
<br /> electrical,unsafe covers Etc. ?_ ' '
<br /> Any"yes"answerlhdicates that the system!s an lmminer�t � "��acl<soll"above soil dis�orsa{system �.1�
<br /> lhreat to publlc hea/th and safety. I� Syslern requires"omargoncy"pumping •
<br /> ❑ Performed dye lesl �
<br /> Does the syslem pose a lhreat to ground C� Yes �No .
<br /> water for any c:andl�lons deemed non- � ❑ Other, r�'�p ,,v A�, ��,,� ^_ I
<br /> �rotective�s determined bV khe InFv�ctof? I _.,__.,`
<br /> "Yes"/ndlcates that N�e system is failing to protecf
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<br /> grot►nd water If"yes", descrfbe fhe candltJon noted; "" •
<br /> � 'No standard prolocol exis�s. This►ist is not exhaus�lve,
<br /> ---�--------,��-����--�- - -•�-•--• . In sequentia/ord�r, nor does it Jndicate which •
<br /> combinatlons are necess2ry to malte thls defermina(iun. �
<br /> Certification � �
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<br /> Tl�ls farm is to be complEk�d and attached lo the Summary FoRn of the Mlnnesote Pollu#ian Canlrol Agency's(MPCA)Compliance
<br /> InSpection Form for Existing 5ubsurface Sewage 7reatmen4 5ystems.'ObseNBlions,interpr�tations,�nd con�lusipns must be i
<br /> compleled by an i�sp�clar.Completed,form must be submitted'[o the local unil of govAmmenl within 15 days.
<br /> Property�wner name(s): �OQj � �i � � �Y -�.,, �
<br /> . Properiy addross• ���L�����..,_..L�gL�r�_��—(�r0�.`d . _.
<br /> Pro�erty owner's 8tldress(If dlffarent)� � � �
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<br /> County: �.��¢�� Property own�r phono: �.�c�� �rJ'?, .- 39� , �
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<br /> 1 hereby cerliFy fhat I personally mede Ihe observallons, Inte�pretafians, and conclusions r'epaled on this form and U�a�rh9y are
<br /> carrect. � �
<br /> Nama; ,� `/��, �, ,����.��� • _,.. Certification number: (o a1 „ ,...
<br /> 8usiness Ilcense name and n�imber: �•� �L��� �y��,, , �L���t�,�� 0)�°�w►�,e�,�.��,��y a� ,
<br /> Name of IoCs�l unit of govemment: � •
<br /> Sign�lure: �'_�__�.��/.�� ""-�"" � � ...,.,.- .�. �...,... DAte'. .L} .��� � O 1[�
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<br /> wwuv.pCa.Stdke.ma.us� •• 651•Z96•6300 • � 800•657•�•8ir�-.�• TTY 651-282-5332 or 600-657-3864 • Available in alternative formaLs
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