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May 171010:59a 763-213-0695 p.2 <br /> Parcel number: 115D t .-t-111Ari fig <br /> ---System status: titr,ompliant ❑ Noncompliant <br /> (as determined by this form) <br /> Hydraulic Performance and Other Compliance <br /> Compliance Issue #1 of 4 <br /> Date of observation: i3-#) Reason for observation: <br /> This form expires upon next inspection or in three years,whichever occurs first: <br /> Compliance questions/criteria: (Required) Verification Method*: (Optional) <br /> (Check the appropriate box) (Check the appropriate box) <br /> Does the system discharge sewage to the ❑ Yes GS No <br /> ground surface? 54Searched for surface outlet <br /> Does the system discharge sewage to drain 0 Yes rig No ❑ Performed hydraulic test <br /> tile or surface waters? 1,21 Searched for seeping in yard <br /> Does the system cause sewage backup ❑Yes MI No l' Checked for backup in home <br /> into dwelling or establishment? <br /> ❑ Excessive ponding in soil system/D-boxes <br /> Do other situations exist that have the ❑Yes 1 No <br /> potential to immediately and adversely Homeowner testimony <br /> impact or threaten public health or safety I Examined for surging in tank <br /> jelectrical, unsafe covers,etc.)? <br /> Any"yes"answer indicates that the system is an imminent "Black soil"above soil dispersal system Iter-e-- <br /> threat to public health and safety. ❑ System requires"emergency"pumping <br /> Does the system ❑ Performed dye test <br /> y pose a threat to ground ❑ Yes al No <br /> water for any conditions deemed non- ❑ Other: <br /> protective as determined by the inspector? <br /> "Yes"indicates that the system is failing to protect <br /> ground water. If"yes'; descrl the condition noted: <br /> *No standard protocol exists. This list is not exhaustive, <br /> in sequential order,nor does it indicate which <br /> combinations are necessary to make this determination. <br /> Certification <br /> This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA) Compliance <br /> Inspection Form for Existing Subsurface Sewage Treatment Systems.Observations, interpretations, and conclusions must be <br /> completed by an inspector. Completed form must be submitted to the local unit of government within 15 days. <br /> Property owner name(s): <br /> Property address: ` "-' 3. 0 0l_ <br /> Property owner's address(if different): ,'�` <br /> County: l/iiyY` C� �/ <br /> Phone: 6 j.; -• - (�7 " <br /> !hereby certify that I personally made the observations,interpretations, and conclusions reported on this form and that they are <br /> correct. <br /> Name: 90-kr— iizte Certification number: ?6--- <br /> Business license name and number: )Z Si+o �, , ' ' <br /> J 93 or <br /> Name of lova; unit of government: <br /> Signature: �4� <br /> Date: <br /> • <br /> wq wwists4-31 Compliance Inspection Form for Existing SSTS <br /> 4/1108 <br />