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2/25/02 Water/Wastewater-I$T54.31 .=
<br /> . . � Compliance Znspection Form for Existir� � •
<br /> Indiv�dual,Sewage Treatment Systems
<br /> . . � . Minnesota Pollut�an
<br /> Comple�ion of this form fulfills:the minimal requlr"ements ol Minn. s � Control Agenry
<br /> to local ordinances for other re utrement�or i�formatfon, es eciallt to com �ance�e)u�e e,nts torrb droom additions. ,
<br /> ( �• Please refer-
<br /> G a �
<br /> Date of Inspection: 1��—`l�f—��
<br /> _ Reason for inspection: �,�[�„�
<br /> Property Owner(s)�- � ,r�o .�.e �^Q as
<br /> Person requesttng tnspection ���",� „ Telephbne� (�'O /-. �1?� ,
<br /> � �i i' Tc��/ Telephone ( )
<br /> site Address 1'D���r„T�,P woo�- R� �
<br /> City o No Zip Code________^
<br /> Fire No./ Parcei Na County , �{ n.
<br /> Legal Description Township
<br /> Local Regulatory Authority
<br /> Date system constructed_/�I Qg
<br /> _ System in Shoreland Area: yes� System in Wellhead
<br /> Protection Area: yes � System serving a MDH licensed facili :
<br /> ty yes �Local permit# (if any)
<br /> Systems built p�ior to April 1, 1996 a�d not located (n Systems located in Shoreland or Wellh
<br /> Shoreland or Welihead Protectlon Area or Serving a Food, ead Protect3on
<br /> Beverage or lodging Establishment Areas or Serving a Food, Beverage o�lodging
<br /> Establishment, or systems Buiit after
<br /> Is h s March 31 199Ei
<br /> af 7 (a yes answe�is an ITpHs i �-�-�+�eRt an imminent threat�o n�bti�tio����
<br /> - Discharge oP sewage to the ground surf�e?m> or safetv? (a yes answer�s an ITPHS system)
<br /> - Discharge of sewage to draint�le or surtace waters? YES N� - Discharge of sewage to draintlle or�u aace waters?Y� NO
<br /> -Sewage backup into dwelling? Y� YES NO
<br /> -5ituation with the potenCfal to immediately and -Sewage backup into dweliing? YES NO
<br /> adversely impact or threaten public heaith or -Situatlon with the potential to immediately and �
<br /> safety? adversely impact or threaten public health or
<br /> YES �� safety? �
<br /> ._ .:..... .:.... ..: .:.. . ...�YES NO
<br /> is the svstem failina� (a y�answeris.a,failin s, t „ ,: ,
<br /> - �ess than TYvO feet of vertical s e p a r a ti o n b e t w e e� 9 ��m,� �.the�svs�em ta11t,nd? (a yes ansrueris a f a i l i n g s y s t e r n)
<br /> system bottom and saturated soil ar bed�ocki � - Less t han THREE f�et of vertical separadon between:
<br /> -A see e �t cess oi d YES�`� ' ',ry�m�tt�;r:,and s`aturated soii or bedrock? YES NO
<br /> �9 p � P° � M�+���,or leathing pit? YES N • -A see a d
<br /> � page pit,cesspool,dryweil, or leaching pit? y� �p
<br /> . ,,,:; .. : :%;..
<br /> Is the svs e�*+ � _. . _ ..,., _
<br /> .. ..
<br /> •. :. : .
<br /> , . , ..
<br /> IIOn-tomelia.,t� _ =-::.
<br /> ._.__. . . _�s-tlte.�rstem_
<br /> - Is the system regulated under a monitorin lan or `
<br /> �1-�omelian#�...._ .
<br /> operating permit? (if no,go to a e 2 9 p r ' �s the system regulated under a monitorin
<br /> p g ) YES �� operating permit? if no, o to a e 2) 9 Plan or •.
<br /> !f yes, . . . . � g p 9 YES NO :
<br /> - Has the required manitoring taken lace? �' .~M If yes; ;
<br /> (1/no, the system is non-com I rn p Y� ,NO �` - Has the required monitoring taken place? Y�S NO �
<br /> p y �} (ll na, the system fs non-com 1 !n '
<br /> PY 9I
<br /> - Does the monitoring indicate that the system meets + - Does the monitoring indicate,thaC the s stem m
<br /> performance expectations? YES NO�� performance expectations? y� ' Bets
<br /> (ll no, the system is non-ccmplying) �YES NO
<br /> (If no, the system is non-comply/ng) .
<br /> ":`._ ; rc:,: ::,.
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