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� ��� �- N�i� <br /> • ' Compliance Inspection Form for Existing <br /> � Individual Sewage Treatment Systems M�nnesota Pollution <br /> � Controt Agency <br /> Completion of this lorm fulfllls the minlmal requirements of Mlnn. Stet.§ 115.65(2001)and Minnesota R. ch. 7080(1999�. Pfease refor <br /> to local ordinances for other requirements or information,especially for compliance requirements for bedroom additions. <br /> n : <br /> Date of inspection: �Reason for inspectlon: 0. <br /> Property Owner(s) Telephone (Qfa) �� � ���� <br /> Person requesting inspection '�"' �- 0.Y� Telephone (� Q�.S-' S��o� <br /> Site Address ✓' City d�Ar'1��._, Zip Code <br /> Fire No./Parcei No. County��� � 1�I Township <br /> Legal Description <br /> F <br /> Local Regulatory Authority <br /> Date system constructed System in Shoreland Area: �no System in Welthead <br /> Protecbion Area: yes � System senring a MDH licensed facility: yes�Local Permit# (if any) <br /> Systems built prior to April 1, 1996 and not located in Systems located in Shoreland or Wellhead Protectlon <br /> Shoreland or Wellhead Protection Area or Serving a Food, Areas or Serving a Food, Beverage or Lodging <br /> Beverage or Lodging Establishment Establishment, or systems Built afEer <br /> March 31 1996 <br /> Is the avstem an imminent threat to public health or �s the svstem an imminent threat to public health <br /> safeNl (a yes answer is an 17PHS system) or safe ? (a yes answer is an 17PH5 system) <br /> -Discharge of sewage to the ground suKace? YES NO - Discharge of sewage to the ground sufiace? YES <br /> -Discharge of sewage to drair�tile or surFace waters? YES NO - Discharge of sewage to draintile or surface waters?YES 0 <br /> -Sewage backup into dwelling? YES NO -Sewage backup into dwelling? YES <br /> -Situation with the potential to immediately and -Situation wfth the potenUal to immediately and <br /> adversely impact or threaten public health or adversely impact or threaten public health or <br /> safety? YES NO safety? YES� <br /> is the svstem faili�a? (a yes answer is a failing system) Is the system fatlina? (a yes answer is a fa/ling system) <br /> -Less than T1N0 feet of verticai separation between -Less than THREE feet of vertical separation hetween <br /> system bottom and saturated soi) or bedrock? YES NO system bottom and saturated sofl or bedrock? ES <br /> -A seepage pit,cesspool,drywetl, or leaching pit? YES NO -A seepage pit,cesspool, drywell, or leaching pit? YE NO <br /> Is the svstem non-comaliant? is the system non-com�liant2 <br /> - Is the system regulated under a monitoring pfan or - Is the system regulated under a monitoring plan <br /> operating permit? (if no,go to page 2) YES NO ope�ating permit? (if no,go to page 2) YES N <br /> If yes, If yes, <br /> -Has the required monitoring taken place? YES NO -Has the required monitoring taken place? YES NO <br /> (lf no, the system is non-complying) (If no, the sysiem is non-complying) <br /> -Does the monitoring indicate that the system meets - Does the monitoring indicate that the system meets <br /> performance expectations? YE5 NO performance expectations? YES NO <br /> (1(no, the system is non-complying) (!f no, the system is non-complying) <br /> Page 1 of 2 wq-wwists4.31 <br /> i 'd Z6ZE-ELS [ZS6l punjpamg ysoC d6Z � i0 LO SZ �oN <br />