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2/25/02 Water/Wastewater-ISTS4.31 compfoance Inspecd n Form ?or E xNstong Sewage reatimient Sy elms Minnesota Pollution Control Agency Completion of this form fulfills the minimal requirements of Minn. tat.§115.55(2001)and Minnesota R. ch. 7080(1999). Please refer to local ordinances for other requirements or information es eci 1 I for compliance requirements for bedroom additions. Date of Inspect.l®n: &1A161 Reason for inspect lon: CWX Property Owners) III Telephone( ) Person requesting inspection Telephone ( ) Site Address .-® A -s-747 /� City Q.QQvD alp Code fire Noo/ Pardel No. County c•',r.- . .cJ Township Legal Description Local Regulatory Authority f Dat®system construact®d Syste in Shoreland Area: yes no System In Wellhead protection Area: yes(VSystem serving a MDH lice sed facility: yeF0 Local Permit# (if any) By-9 Systems built prior to April 1, 1996 and not located in Systems located in Shoreland or Wellhead Protection Shoreland or Wellhead Protection Area or Serving a Foo , Areas or Serving a Food, Beverage or Lodging Beverage or Lodging Establishment Establishment, or systems Built after March 31 1996 Is the isstfstem an imminent threat to g ublic health or Ys the sssteun an imminent threat to guub is health g ? (a.yes answer is an ITPHS system) or saffeV? (a yes answer is an 17PHS system) -Discharge of sewage to the ground surface? YES NO -Discharge of sewage to the ground surface? YES -Discharge of sewage to draintile or surface waters? YES NO -Discharge of sewage to draintile or surface waters?YES -Sewage backup Into dwelling? YES NO -Sewage backup into dwelling? YES IV -Situation with the potential to immediately and -Situation with the potential to immediately and adversely impact or threaten public health or adversely impact or threaten public health or safety? YES NO safety? YES (05 19 the$Xs_teun flailing? (a yes answer is a failing system) Is the VsteM failing? (a yes answer is a failing system, -Less than TWO feet of vertical separation between -Less than THREE feet of vertical separation between system bottom and saturated soil or bedrock? YES NO system bottom and saturated soil or bedrock? YES XV -A seepage pit,cesspool,drywell,or leaching pit? YES NO -A seepage pit,cesspool,drywell,or leaching pit? YES Is the UsteM non-compliant? Is the est m non-comallant? Is the system regulated under a monitoring plan or a Is the system regulated under a monitoring plan o operating permit? (if no, go to page 2) YES NO operating permit? (rf no,go to page 2) YES If yes, If yes, -Has the required monitoring taken place? YES NO -Has the required monitoring taken place? -YES NC (If no, the system is non-complying) (If no, the system is non-complying) -Does the monitoring indicate that the isystem,meets -Does the monitoring indicate that the system meets performance expectations? YES NO performance expectations? YES NC (If no, the system is non-complying) (If no, the system is non-complying) Pana 1 of lain-tnnnliC>Cd '41