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�"'; <br /> i <br /> � Compliance Inspection Form for Existing <br /> � Individual Sewage Treatment Systems <br /> v <br /> This form reflects the requirements of the 1996 version of MN Rules Chapter 7080 <br /> Minnesota Pollution Control Agency <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: >; • ,i � - -f': r' �' <br /> Property Owner(s)�:`;��,�:,� f' - �r��: 2`�`� �. Telephone( )�,�..fi�-�� <br /> >---�.—�• <br /> Person requesting inspection'(if different than owner) Telephone( ) <br /> Reason for inspection: _�'r�/. . ,� <br /> Site Address - r - a.%� �`, �: 'F <br /> c � f. f' ati.: City ('", (;.:; �•C.i <br /> Zip Code�� . . Unrt of Government Regulating this property �Y ,,��j �: �,� :�_ .-� <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 s : Soii Treatment Sy�tem: Other(briefly describe�: 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, P�,%t � <br /> Holding tank Seepage bed Exp.Date: <br /> Other Mound Other <br /> _At-grade <br /> Svstem 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(IPHTI?U�grade Is the system an IPHT? Upgrade <br /> 1.Discharge of sewage to the ground surface? YES ,'NO ]0 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 l0 mo surface waters? YES NO 10 mo <br /> 3.Sewage backup into dwelling? YES �' 10 mo 3.Sewage backup into dwelling? YES NO ]0 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 adversely impact or threaten public health or <br /> safety? YES �NO ]0 mo safety? YES NO 10 mo <br /> Is the svstem failing? 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 t�e,system status is (check one)�in compliance(functioning)❑failing�an imminent threat <br /> therefore,this document is a(check one)�.1 Certificate of Compliance ❑,Notice of Noncompliance. <br /> Page 1 of 2 <br />