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��r.�m , <br />��.. . ����. ��... � .�����, �ar.=` ...�.. <br /> , - Compliance Inspection Form for Existing -. �, � <br /> 4aifaa` ; ,.��,�`b�,���J <br /> Individual Sewage Treatment Systems <br /> � <br /> This form reflects the requirements of the 1996 version of MN Rules Chapter 7080 � R �R�� <br /> Minnesota Pollution Control Agency ��Y ; <br /> Note:Local inspection standards may be more or less restrictive than the state requirements. These differences must be made available by the Local <br /> Unit of Government. <br /> Date of Inspection: s <br /> Property Owner(s) �;; ; :. Telephone( ) b��.`E/f.'�-` :',� <br /> Person requesting inspection(if different than owner) Telephone( ) <br /> Reason for inspection: <br /> Site Address ' - City =. � : � > <br /> Zip Code Unit of Government Regulating this property r`r <br /> Fire No. Parcel No. Township Name � <br /> Township Range Section Quarter <br /> (Check appropriate sewer system component and indicate location on site sketch). <br /> Tank Soil Treatment System: Other(briefly describel: Flow Meter <br /> ;: Septic tank ° Rock trench _Alternative system __ <br /> _Aerobic tank _Gravelless pipe trench _Experimental system Yes NO <br /> Pump tank Chamber trench Warrantied system If yes, <br /> Holding tank Seepage bed Exp.Date: <br /> Other Mound Other <br /> _At-grade <br /> �stem Classification <br /> System Built Prior to April 1, 1996 and not Located in Any System located in Shoreland or Wellhead <br /> Shoreland or Wellhead Protection Area or Serving a Protection Area or Serving a Food, Beverage or <br /> Food, Beverage or Lodging Establishment Lodging Establishment, plus all systems Built after <br /> April 1, 1996 <br /> Is the sXstem an imminent public health threat(IPHT)?U�grade Is the system an IPHT? Upgrade <br /> 1.Discharge of sewage to the ground surface? YES NO 10 mo 1.Discharge of sewage to the ground surface? YES NO 10 mo <br /> 2.Discharge of sewage to draintile 2.Discharge of sewage to draintile or <br /> or surface waters? YES NO 10 mo surface waters? YES NO 10 mo <br /> 3.Sewage backup into dwelling? YES NO 10 mo 3.Sewage backup into dwelling? YES NO 10 mo <br /> 4.Situation with the potential to immediately and 4.Situation with the potential immediately and <br /> adversely impact or threaten public health or adversety impact or threaten public health or <br /> safety? YES NO 10 mo safety? YES NO 10 mo <br /> Is the system failin�? Is the system failing? <br /> 5.Less than TWO feet of vertical separation between 5.Less than THREE feet of vertical separation between <br /> system bottom and saturated soil or bedrock? YES NO LGU** system bottom and saturated soil or bedrock? YES NO LGU** <br /> 6.A seepage pit,cesspool,drywell,or leaching pit? YES NO LGU** 6.A seepage pit, cesspool,drywell,or leaching pit?YES NO LGU** <br /> ** LGU=Local Unit of Government ordinance must specify the time period within which the system must be upgraded. <br /> STATUS OF THE SYSTEM <br /> Based on the compliance criteria above the system status is (check one),❑in compliance(functioning)C3 failing❑ an imminent threat <br /> therefore,this document is a(check one)❑Certificate of Compliance �Notice ofNoncompliance. <br /> , , _ <br /> F <br /> � Page 1 of 2 <br /> ; <br /> � - <br /> a � : <br /> . . <br /> : � �, . , <br />