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10/08/2010 01:50 7634975011 SPTESTINGINC PAGE 05/07 Parcel number. _ System status: 10 Compliant ❑Noncompliant (es detemuned by this forme) Hydraidic Performance and Other Compliance- Compliance inspection frown for Existing SSTS Compliance Issue 1411 of 4 Date of observation: d�.p Reason for observation: � 9e� This form expires upon next inspection or In three years,whichever occurs first: Compliance questions t:riterla: (Required) Verification Method*: (Optional) __fCheck the--pprapriate boil_ (Check the appropriate box) Does the system discharge sewage to the ❑Yes ®No ground surface? Cl Searched for surface outlet Does the system discharge sewage to drain LlYes ❑No ❑ Performed hydraulic test tile or surface waters? _ ® Searched for seeping in yard 14A Does the system cause sewage backup ❑Yes NQ No ❑ Checked for backup In home info dwelling or establishment?•„_. ®' Excessive ponding in soil systemM-boxes 140 Do other situations exist that have the ❑Yes IM No P911ential to Immgdistely and adversely ❑ Homeowner testimony impact or threaten public health or safety ❑ Examined for surging in lank �elaclrical,unsafe covers etc. ? "�'-'°"- - ® "Black soil"above soil dispersal system Any"yes”answer IndicatP,s that the system is an imminent threat to public health and safety. ❑ System requires"emergency"pumping ❑ Performed dye test Does the system pose a threat to ground Q Yes W No water for any conditions deemed nary- ❑ Other: _protective as d• ermined by.'the Inspector? "Yes"Indicates that the system Is failing to protect " ground inter_N"yes", descrlbe Nle condition noted. . "No standard protocol exists. This list is not exhaustive, " • in sequential older,nor does 9 Indicate which combinations ars necessary to make this determii7stion. Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compliance Inspection Foram for Existing Subsurface Sewage Treatment Systems.Observations,interpretations,and conclusions must be completed by an Inspector. Completed form must be submitted to the local unit of government within 15 days, Property owner name(s): Property address: L_ _ J40 Property owner's address(If different): _ County: r _ Property owner phone- 1 hereby certify that I personally made the observations, Interpretations, and conclusions reported an this form and that they are correct. Name: G I-eb, Certlticatlon number: ba q Business license name and number. '�-, Name of local unit of government: _ or Signature: , -..,....� — Date: 9ojr�© www.pcastate,mn.us • 651.296-6300 800-657.1864 TTY 651•;82.5332 er 800-657-3064 " Available'In altemative formats wq-wwbsts4-31 • 4124109 Rte-7-en