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L/L7/VL vra►a/vvao�crva�c� a.+�..+���i <br /> � i "i <br /> . � Compliance Inspection Form for Existing <br /> Minnesota Pollution <br /> Individual Sewage Treatment Systems Control Agency <br /> Completion of this form fulflUs the minimal requirements oFMinn. Stet. § 115.55(2001)and Mlnnesota R. ch. 70B0(199�. Please reter <br /> to local ordinancss for other ra uiremente or information,ea eciall for com lianca re uiremants Far bedroom additions. <br /> General �� � � � ►��� , <br /> Date of Inspection: Reason for inspection: � � <br /> Property Owner(s) GV 7elephone ( ) <br /> Person requesting inspection ' Telephone ((�l�) $sd" 7�3p <br /> Site Address ✓f�► K2 � � City l'/'�Dl�l D Zip Code �6 <br /> Fire No./ Parcel No. County �r1n i� Township <br /> Legal Description <br /> Local Regulatory Authority <br /> Date system constructed � �r� r q(pS�►stem in Shoreland Area: yes� System in Welihead <br /> t <br /> Protection Area: yes � System serving a MDH licensed facflity: yes � Lccal Permit# (if any) <br /> Systems built prior to April 1, 1996 and not located in Systems located in Shoreland or Weilhead Protection <br /> Shorefand or Wellhead Protection Area or Serving a Food, Areas or Serving a Food, Severage or Lodging <br /> Beverage or Lodging Establishment Establishment, or systems Built aRer <br /> March 31 1996 <br /> Is the��r��^ �^ i^�minent threat to nublic heaith or Is the�stem an imminent#hreat to oublic health <br /> safe ? (a yes answer!s an ITPHS system) or safetv? (a yes answer is an I7PH5 system) <br /> -Discharge of sewage to the ground surface? YES 0 -Discharge of sewage to the ground surtace? YES NO <br /> -Discharge of sewage to draintile or surface waters? YES -Discharge of sewage to draintile or surtace waters?YES NO <br /> -Sewage backup into dwelling? YES -Sewage backup lnto dwelling? YES NO <br /> -S(tuation with the potential to immediatety and -Sftuation with the potential to immediately and <br /> adversely impact or threaten public health or adversely impact or threaten public heafth or <br /> safery? YES � safety? YES NO <br /> Is the svstem failin4? (a yes answer is a failing syst�m) Is the svstem failina? (a yes answer is a fail/ng system) <br /> -Less than TiNO feet of vertical separaaon between -Less than THREE feet of vertical separation between <br /> system bottom and saturated sofl or bedrock? NO system bottom and saturated soil or bedrock? YES NO <br /> -A seepage pit,cesspoo{, drywell, or leaching pit? NO -A seepage pit, cesspool, dryweli, or leaching pit? YES NO <br /> Is the system non-comaliant? is the svstem non-comatlant? <br /> - 1s the system regulated under a monftoring plan or - Is the system regulated under � monitoring plan or <br /> operating permit? (if no,go to page 2) YES � operating permit? (if no,go to page 2) YES NO <br /> if yes, I f yes, <br /> -Has the cequired monitoring taken place? YES NO - Has ihe required monitoring taken place? YES NO <br /> (If no, the system is non-complying) (I(no, the system is non-complying) <br /> -Does the monitoring indicate that the system meets - Does the monitoring indicate that the system meets <br /> performance expectations? YES NO performance expectations? YES NO <br /> (If no, the system is non-complying) (11 no, the system is non-complying) <br /> Page 1 of 2 wq-wwists4.37. <br /> t •d z6ZE-ELB (ZS6l puntpamg ysor e9Z �90 90 6T I�C <br />