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<br /> Parce:m:m�:�.: Sy�,�;rri,tatc,s' �Comp�iar> ❑Noncempliz�t
<br /> (as C'�!r,...,rr�nt!by'!�.i<r•s;r.,;
<br /> Hydraulic Per#ormance and Dther Comp(9ance-Campfianse lnspection F�r,m f:��Existing SSTS
<br /> Compliance issue#1 af 4
<br /> Cate of�hserr<=s�c:i 4/06/2010 Reason for�;hser:�atir;n Real Estate Transadion
<br /> This•c,_..-x_..^°upon next insr�:-?:c^or in ihree years.whiche��r c7cctus`rs•
<br /> Compt9ance questions?criteria:%Rrnuirea) Veri�cation Atlethad':(Cpt��na�)
<br /> (Chnck nc�n,,nwf:;`^r,R^boxl (Cbec{r fnc,�A;;taPnate Aox)
<br /> Does the sys"r,m d;sw`.�..^�-:,e::�ge to Ihe , �Yos �No "' c��.rhnC`or surface ouNet
<br /> grounC s:�rface': �
<br /> . .--. (`.-,t�nf`?1C`d h ,+.'::!�IC:n5�
<br /> �O!?5' .Sy .^1 �1 �h�.�...:?c_•.'?^C YO'�.., ; ❑Va4 l:']I NU �
<br /> tile or si�` e :::e � ~ i ; Cearched(or s:^ep;ng�n yarA
<br /> �oe.^.5����sysler^a,-�:sse se�v,^,qe:backup � �Yes �' No t_� ���p�P��o"h�rkup�n home
<br /> ;...yt.�ning or� �. _..
<br /> [� f x�e =•��pord:r,g m soil sys'em'7-boxes
<br /> pc^•tior situalions exist?`-a . .��he ❑Y�s I�Nr, �
<br /> " � . . ^:cn� ..,."ory
<br /> p�•c^,;�I to!_c.-,.�tely;,_�a•+v,-.. J
<br /> .^��aC or!� ..- p�t'!��.'4c��o�safet;� . . , crac�ined for s ;'.r�y in tan<
<br /> roi�-•.-a� unsafec-:•:a-� etaj?
<br /> � � � �, "Biack soii"ab�ve s,^i!�isr c:rsal sysiem
<br /> Any"yes"answer;nrticntes Chat the sySMm is an ir,mirrcnt
<br /> _ ..�....��„f.c5'�Tr:r���r- ' ^�•n
<br /> thraa2 t0 publie lie.�lfh aad S¢ie2Y• LJ SY�� � � - . . � -7 P�%.���, g
<br /> � Perfarrned dye test
<br /> Oecs�e a�.t�:^ �_c a thrr�to 9�rn;c�i �-" 'es '.��]No `; Othec
<br /> weter!: 'my�:.:r:�'•':-d^c^.':d r..^ `_
<br /> pra:^�-!i�:e as rte'e�na�:•,.�4 by•`�c ir.<,�ec;;,r'
<br /> "Yes"rndicates�hat N�c�system is iailing to pr+tact
<br /> graund wa,'er 1f"ycs",�esr.ribe 1he co»dr2ion nated:
<br /> '!Jn�'.�n�1t�rO p���i-,col��rs'� Thu fist�s not exhaustive.
<br /> in srq;�er`,il ptTlet,nor doBS it indiCate which
<br /> cor,:b,r+at;mr,arc�rer.r,ssary iu make this de!c�^�natior�
<br /> Certification
<br /> s`orm is to be ^�'c�tee ��r nt��ehed to the S�rrenary Fc,rm vf fhe M"nn�s�i�+R C:afio��en;rol Rgency s(MPCA}Compliance
<br /> !��spec.tian Forr.T'or Ex;stng Si�hsurfaee Sewage Treatment SysYems.Obsc-�.•atiens.ie;e�retations.and conciusians�nust be
<br /> c^r��ct�.;�.�by an+r�^�cCor.C^^�w!ct��!;-:rrr must be submrtted t�thr,bra°uni4 ot rc;ramr�?a^?hin i5 tlays.
<br /> Prr, ..rer�a^,�!s) �s^k G�wned
<br /> P•�se . :-,_._��s: 85 L::cn!.�ne Rid�e
<br /> p�„hert'd.�wr.?:c���arrc5(if�+��:���.:- .
<br /> Counry; k"r�� , F:,,p�:Ry���+nerpP�rna
<br /> i he-F+hr . ,���'!per-c.,.�r •rxie�hn �}:sn;...-.�rs rn'e�rmmt•rl�or,s ,�n,!,.<<..�.:;ions�epo;ti��nn this fo,7n and thn'�hgy 8rC
<br /> t n^i^r:.
<br /> Name (";.:� :,`,���ski C�.�s`rc .^n numt:er 65
<br /> B:s:n� re^sn �.���^.r and n���^her _ask:n�ki SeGC..Service � or
<br /> N.'^'( 0 ... ... •ot oc.,-�'7�fr.^��J,�� f",pr n;C,�p.
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<br /> Sianature. � �' � � Ddte 4106120't0
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<br /> �'r,:v�.-,r�,^..-�.�^.n.iz • 65t�19b-o30Q • 800-%r;'�+Rt,a . 7?`%65t�782-i332or 940�857�38G4 . Availabie m a'Ls.�ative fn�—a.s
<br /> wn.K+v°<tc.a 3i . •li2•;�09 �-ot�20J8
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