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01/24/2008 01:30 7631975011 SPTESTINGINC PAGE 03/07
<br /> 2/2./02 ' Water/Wastewater-I5T54.31
<br /> C6,M111.1 nce,lnspectflon (Forge for B�&Ung
<br /> XC clivi %W sewage Treatment Systems l`+lino7epota Pml➢u'don
<br /> =�a,s +CoIntrol Agency
<br /> Comp/anon of 11718 foml fu117/1s pie Minimal mqufmments nfMhln.Stah 9 ii5.55(2001)•and Minnesota R.ch, 7080„(/999). (Tease refer
<br /> to local ordlna cos for,diher re ui efndnis rarinform tion es eolall f r:oo (lance re uiremente Jor bedroom additions.
<br /> General
<br /> Datr+d of Inspecdton: 14.-v • (Reason foe Inspectiont -
<br /> Property ownerrs) Sri\4s•4 i :Iwo i'6't A. 2 Telephone,
<br /> Person regoesting•lnispection lSfAti.R�i Telephone( )
<br /> Site Address S10) 1 Citg/, Zip Code
<br /> FW8 No./ parcel No. � Coln'nty.,1�Gn!)4*4 SAO Townshlp
<br /> Legai Description
<br /> Local itegalatoryAuthority G� �'� D� �9!-�0
<br /> Date system constructed' 9 at_3_-SS 7Syst4m in Shbreland! rams no System in illfellhead
<br /> Protection,Area., yes rio System 15®rvlamcq a MPH licensed facility; yes ri1 Laft[Vermit#(if any)
<br /> Sys:Wrns built prioi.to April 1, 1906 and not located in Systems'located In-Shomland{or Wellhdad.Pralection
<br /> Shoreland or Wellhead Prbtectlon•Area eir Serving a'pood, Areas ur Serfing,a Food;Beverage.or•Lodging
<br /> j' Beverage or Lodging bushinent' • EstabOhment,or evs!Zms Quilt afteir
<br /> March 3141-996
<br /> Is the systlem an•ill mbitn9:ilhm- A do i-ublic henith mr Isthe astern.an 101iv>t�nent threat t® 601116 health
<br /> safe a' ansi�ver Is ar7ITm�51� t@M �
<br /> Yom' J••• dr'saifetva•(�'y�sans`warlsanl�PHssysramJ
<br /> -Discharge of Sewage to tlie,gMund suArce? YES NO -DI.Sdaargo ofsewage to the ground surfage7 ),)!S_ O
<br /> -Discharge df sewage to drdifitlle or surface wet=? YES Np •-pisctorgs of sewage to•draintlle or surface wattrs?Yt,s
<br /> -
<br /> Se back Into dwelling? ••YES NO -5ewagehadcup Into dW®Idng? ,YES
<br /> -SltuaUvn WM the potantlal to Immedlat- ly and -SlUtion with the potential to immediately and
<br /> adversely impact•or threaten public belalth•or adversely impact or Ali wtegn public hrraltta:or .
<br /> safely? YES NO• 6fety? YFS CO)
<br /> Ts • , mss oslem-falling? (a j as anspIF.a fa/Iltlgsys em) Is tte s�ste i l aL(a yes.answer'Ps`a falling system)
<br /> Less thah Trot!&feet of vero al,separiltl, n be en, -Less khan•."lt�l�feel:oF•ver.tical••separallop•bei�Veeii,:,�,
<br /> systhm-bottom••aha'vWrated soil ur:kt•diock? ' - •'Y�s '•NO .6m.M boltdm d6d; Wik ted sol)or bedrock? YES (l
<br /> -A seepage tilt,cesspool,drywell,or-teaching pt? YES,'No -A seepage pit cesspool,drywall,or leaching Olt? ' ' YEs t N�
<br /> �t to s rstern non�c� p➢iant.B �s'�ln�s9vsterla thou-ciatRe liant? :dv
<br /> - ,is the s)ystom reguleted'urider a moilto'ring plan or Is ihe' _4pt9l'1'1•regulated under a.monital7ng plan or
<br /> operating permit? (ff no,.go to page 2) YES NO opecsting permit?'01nv,go(a pag e•2) -YES
<br /> If yes, If yes,
<br /> -Was the required monitorinj token p�aoe7 YES. NO -Has the required motiltoring taken pld6il NO
<br /> •lff no, the system is norp•complylgg) I (if no,Yhe•eYetem bnon'�cftplyfng)
<br /> is ,
<br /> '•Does.tho monitorih indloate al t -
<br /> 9 ha th�aysfeni inebta Doegtft manitoiing inc11c;i*thd(1hv system meat&-
<br /> porf rmdtice a eotatfdhil :. I, :; ;.
<br /> 'R'�., ,• � p ; , .,1�© f6txiia[�gq,epectatii ,e4 , a ate' No
<br /> (If no, ;1Fi sy�fririi fd-n?n-rbralplying) (Ifnv, the system Is nun-aomplyfn91
<br /> I
<br /> • ,.y, i .' .' , .„ , . ;f lis
<br /> Parc 1 0f 2 . vvq-wwists4.31 "r`
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