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1/29/02 Water/Wastewater-ISTS4.31 <br /> Com liance Inspection Form for Existing <br /> Ind vidual Sewage Treatment Systems Minnesota Pollution <br /> Control Agency <br /> Completion of this form fulfills the inimal requirements of Minn. Stat. § 115.55(2001)and Minnesota R. ch. 7080(1999). Please <br /> refer to local ordinances for oth= re•uirements or information, es•:ciall for corn•liance -•uirements for bedroom additions. <br /> General: <br /> Date of Inspection: _4/7/06 Reason for inspection:_Building Permit <br /> Property Owner(s) 3amie L'we Telephone( ) <br /> Person requesting inspection 3 - Ripley Telephone(952)_449-5746 <br /> Site Address_105 Orono Orcha • Road City_Orono Zip Code_55359 <br /> Fire No./ Parcel No. County_Hennepin Township <br /> Legal Description <br /> Local Regulatory Authority_Ci of Orono Date system constructed_no data <br /> System in Shoreland Area: yes 1,M• System in Wellhead Protection Area: yes no <br /> System serving a MDH licensed •cility: yes Local Permit# (if any) <br /> Systems built prior to April , 1996 and not located in Systems located in Shoreland or Wellhead Protection <br /> Shoreland or Wellhead Prot-• 'on Area or Serving a Food, Areas or Serving a Food, Beverage or Lodging <br /> Beverage or Lodgi g Establishment Establishment, or systems Built after <br /> March 31 1996 <br /> • - 7•_ t'► - , . ' h 1 •r Is the system an imminent threat to public health <br /> safety? (a yes answer is an 'HS system) or safety? (a yes answer is an ITPHS system) <br /> - Discharge of sewage to the groun• surface? YES NO -Discharge of sewage to the ground surface? YES 00 <br /> - Discharge of sewage to draintile o surface waters? YES NO -Discharge of sewage to draintile or surface waters?YES 0-0 <br /> -Sewage backup into dwelling? YES NO -Sewage backup into dwelling? YES -00 <br /> -Situation with the potential to im ediately and -Situation with the potential to immediately and <br /> adversely impact or threaten pu•lic health or adversely impact or threaten public health or <br /> safety? YES NO safety? YES 0-0 <br /> Is the system failing? (a yes -nswer is a failing system) Is the system failing? (a yes answer is a failing system) <br /> - Less than TWO feet of vertical se••ration between -Less than THREE feet of vertical separation between <br /> system bottom and saturated • I or bedrock? YES NO system bottom and saturated soil or bedrock? YES 00 <br /> -A seepage pit,cesspool,drywell, "r leaching pit? YES NO -A seepage pit,cesspool,drywell,or leaching pit? YES 1'0 <br /> •.L 7•_ 11 I.• Is the system non-compliant? <br /> - Is the system regulated under a monitoring plan or - Is the system regulated under a monitoring plan or <br /> operating permit? (if no, go to •age 2) YES NO operating permit? (if no, go to page 2) YES 0-00 <br /> If yes, If yes, <br /> - Has the required monitoring taken place? YES NO - Has the required monitoring taken place? YES NO <br /> (If no, the system is non-complying) (If no, the system is non-complying) <br /> -The monitoring indicate that the system meets -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 />