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'Parcel number; - System status: Compliant 0 Noncompliant (as determine by Is form) • Hydraulic Performance and Other Compliance Compliance Issue #1 of 4 Date of observation: • Reason for observation: This form expires upon next inspection or in three years,whichever occurs first: Compliance questions/criteria: (Required) Verification Method": (Optional) (Check the appropriate box) (Check the appropriate box) Does the system discharge sewage to the 0 Yes No )(Searched for surface outlet ground surface? Does the system discharge sewage to drain 0 Yes No ® Performed hydraulic test tile or surface waters? 'Searched for seeping in yard Does the system cause sewage backup 0 Yes No 0 Checked for backup In home into dwelling or establishment? 0 Excessive ponding In soil system/D-boxes Do other situations exist that have the . 0 Yes No potential to immediately and adversely 0 Homeowner testimony impact or threaten public health or safety Examined for surging in tank Jelectrical,unsafe covers,etc.)? Any"yes"answer indicates that the system is an imminent 0 "Black soil"above soil dispersal system threat to public health and safety_ ❑ System requires"emergency"pumping 0 Performed dye test Does the system pose a threat to ground 0 Yes No [] Other water for any conditions deemed non- protective as determined by the inspector? _....... "Yes"Indicates that the eystem is falling to protect ground water. If"yes", describe the condition noted: • No standard protocol exists. This list is not exhaustive, -••-� in sequential order; nor does it indicate which combinations are necessary to make this determination. Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compliance Inspection Form 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): ,IA ' i /'y�_ Property address: 9.6V 1 ]�Tyt�f1T, • .1&.1 ,�1 U Property owner's address(if different): ' County: Phone: I hereby certify that I pe onaliy made the observations, interpretations,and conclusions reported on this form and that they are correct. • } Name: ar► �— 1V 4 Certification number: 11.1651 Business license na a and mber: ♦ :�` • ,ff1C.•i i or Name of local unit /•ov= ment • A Signature: A_ / Date: 3 a f)-- wq-wwists4-31 Compliance Inspection Form for Existing SSTS 4/1108 • 50/60 39Gd ZTTEEL8Z96 Zt7:ET ZtOZ/EZ/E0