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08/19/2011 13:55 9528733112 PAGE 02/05 <br /> parcel nurnber: <br /> �___� <br /> � ~~~~—�-----�," System status: Compliant <br /> fas deterrnrne��s� ❑Noncor►�plian! <br /> Nydraulic Perfo� °'�'� <br /> Cornp�fance Issue #� f e and Other Cor„p��a��� <br /> Date of observation: � , <br /> This form expires upon ne�ct ins Reason for vbservation: �_. � <br /> P�tion or in three yrears� yyhichever p�����t <br /> �ampilance questions/criteria: iRequired) <br /> Check the a ri$re� Verificatfon •. ` '- — <br /> Ooes the system discharge Sewa9e ro mQ Method . (Optionaq <br /> . round surface? (]Yes � No (�heck tha epprnpr�ete 6ox) <br /> Does the system discharge seuva e to drdin �e'�ed For su�Face outlet <br /> tile or surFace yyaters? 9 ❑Yes No � Performed hydraulic test <br /> Does the system cause sewage backup �ea�ched for seeping in yard <br /> Into dweilin or establishment? Q Yes N� ❑ Checkad f�or backup in home <br /> Do other situations exi�t th�t have the � ��essive pcnding in so1l system/D-boxes <br /> potential to immediately and adversety ❑Yes No <br /> impact or threaten public health or s�fety ❑ Homeowner teSNmony <br /> e�ectrlcai, �nsafe covers etc.? ❑ Examined fi�r surgirig in tank <br /> Any��yes�arrswe�/ndlc�tea that the systenr/s an lmminent ❑ "B�a�5011"above soil dispersal system <br /> threat fo publlc hea/�h and safety, <br /> ._ a System nequlres'emergency'pumpEng <br /> Does the system pose a threat b ground � P��o�ed dye test <br /> water for any conditions deemed non- ❑Yes Wo <br /> �utective as determined b the in n ❑ Other: _ _ _ _ ____ � <br /> �^ <br /> "Yea"indicates that tlre syslern/s�a/�ir�g ro p��ct -- <br /> ground water. !f'�nes'; describs the condrt/on noted: � <br /> ',�:. — .—..— _... .. <br /> -�---� *No standard prctoco!exists. This list is Rot exhaustive, <br /> in sequenlial order,nor does it indicate which <br /> -"� � comb;nations sre necessary to make this determinafion. <br /> Certification <br /> This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compltance <br /> Inspect�on Form for Existing Sub:urface Sewa�e Treatme�t Systems.Observations,interpretations,and conclusions must be <br /> completed by an inspector. Completed form m at be submitted to the Iocal unit of govemment within 1S days. � <br /> Properry owner name(s); <br /> Property address: —' --.---.— •-•- .._. <br /> � <br /> Property owne ' addr�ss(If difFerent): —�—� ---• <br /> County: Phone: <br /> I hereby certify thaf!personslly made the observatians,inferpretations, and concluslons neperfed q�this lorm and that fhey are <br /> r.orrect, <br /> Vame: �1 G�1 p�,� <br /> ` Certification number: ���� <br /> 3usiness license name and number; � --- . � <br /> �ame of local unit em . _ or � <br /> t: ••-- <br /> ignature: <br /> � Date; <br /> �vwrscs4-31 <br /> 08 Comp(iance/nspect;on Forrr, fnr���«:.,,. «TM <br />