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2/25/02 Water/Wastewater-ISTS4.31 <br /> _ �► � Compliance Inspection Form for Existing <br /> If1dIVIC�L11� S@W89e TI"eat111E11t S�/SteR1S Minnesota Pollution <br /> � Control Agency <br /> CompfetJon of this iorm fulfills the minimal requirements of Minn. Stat. § 115,55(2001)end Minnesota R. ch. 7080(i999�, Please refer <br /> to local ordinances for other requirements or intormation,especielly for complience requirements for bedroom additions, <br /> G ra <br /> Date of Inspection: Rea n for inspection: �(.�< <br /> � <br /> Property Owner(s) l� 'Telephone ( ) <br /> Person requesting inspection Y� � �Yl Telephone ((pl�. $17'���� <br /> Site Address City [��� Zip Code�����o <br /> Fire No./Parcel No. County � , C,�I� � �.r/ Township <br /> Legai Descriptlon <br /> Local Regulatory Authority <br /> Date system constructed System in Shoreland Area ye no System in Wel[head <br /> Protection Area: yes�5ystem serving a MDH licensed facility: ye o ocal Permit # (if any) <br /> Systems built prior to April 1, 1996 and not located in Systems located in Shoreland or Wellhead Protection <br /> Shoreland or Wellhead Protection Area or Serving a Food, Areas or Serving a Food, Beverage or Lodging <br /> Beverage or Lodging Establishment Establishment, or systems 8uilt afiter <br /> March 31 1996 <br /> Is the svstem an imminent threat to nublic health or Is the svstem an imminent threat to oubiic health <br /> e ? (a yes answer is an I7PH5 system) or sa#etv? (a yes answer is an ITPHS system) <br /> -Discharge of sewage to the ground surface? YES NO - Discharge of sewage to the ground surface? YES f� <br /> -Discharge of sewage to drain�le or surFace waters? YES NO -Discharge of sewage to draintile or surface waters?YES <br /> -Sewage backup into dwelling? YES NO -Sewage backup into dweiling? YFS <br /> -Sftuation with the potential to(mmediately and -Situation with the potential to immediately and <br /> adversely impact or threaten public health or adversely impact or threaten public health or <br /> safety? YES NO safety? YES � <br /> is the svstem failing? (a yes answer is a failing system) Is the svstem failing? (a yes answer is a failing system) <br /> -Less than T1N0 feet of vertical separation between -Less than THREE feet of vertical separation between <br /> "system bottom and saturated soil or bedrock? YES NO system bottom and saturated soil or bedrock? YES <br /> -A seepage plt,cesspool, drywell, or leaching pit? YES NO -A seepage pit,cesspool, drywell, or leachfng pit? YES <br /> Is the svstem non-comnliant? Is the svstem non-comuliant? <br /> - Is the system regulated under a monitoring plan or - ls the system regulated under a monitoring plan <br /> operating permit? (if no,go to page 2) YES NO operating permit? (if no,go to page 2) YES <br /> If yes, !f yes, <br /> - Has ihe required monitoring taken place? YES NO - Has the required monitoring taken place? YES NO <br /> (Il no, the sysfem is non-complying) (If 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) (If no, the system is non-complying) <br /> Page 1 of 2 wq-wwists4.31 <br /> T 'd z6Z£-EG8 [zS6] puntpamg ysoC eib �0i 90 EO �oN <br />