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L/L]/VL VVGIc�/vvaa�crvo�u 1.JIJ��J1 <br /> � i <br /> ,�� Compliance Inspection Form for Existing Minnesota Poltution <br /> i.,.��r4� Individual Sewage Treatment Systems Control Agency <br /> �.r <br /> Comp�etlon of this form fulftlls the minimal requirements of�Minn. Stat.§ 1 J5.55(2001)and Mlnnesota R. ch. 7080(199�. Please refer <br /> to local ordinances ior other ra uirements or informatlon,es eciall for com liance re uirements for bedroom additlons. <br /> Gene I: <br /> Date of Inspection: Reason for inspection: a � <br /> Property�wner(s) lN �G✓l 'Telephone ( ) <br /> Person requesting inspection i Telephone ((�!�) �SO - 7�3p <br /> Site Address <br /> ✓� �, � City �/�Dl2� Zip Code �6 <br /> Fire No./ Parcel No. County�� Township <br /> Legal Description <br /> Lucat Regulatory Authority <br /> Date system constructed ? P�r� rn_�o 14Q�p5ystem in Shoreland Area: yes(�2 System in Wellhead <br /> Protection Area: yes � System serving a MDH lice�sed facility: yes � Locat Permit # (if any) <br /> Systems built prior to Apri1 1, 1996 and not located in Systems located {n Shoreland or Wellhead Pratection <br /> Shoreland or Wellhead Protection Area or 5erving a Food, Areas or Serving a Food, Severage or Lodging <br /> Beverage or Lodging Establishment Estab(ishment, or systems Bui1t after <br /> March 31 1996 <br /> Is the svstem an imminent threat to nublic health or �.s the svstem an imn�inent threat to oubfic health <br /> safe ? (a yes answer is an 17PHSsystem) or safetv? (a yes answer is an ITPHSsystern) <br /> -Discharge of sewage to the ground surface? YES 0 - Discharge of sewage to the ground surtace? YES NO <br /> -Discharge of sewage to draintile or surface waters? YES - Dlscharge of sewage to draintile or surtace waters?YES NO <br /> -Sewage backup into dwelling? YES -Sewage backup into dwelling? YE5 NO <br /> -S(tuation with the poten�al to immediately and -Situation with the potential to immediately and <br /> adversely impact or threaten public health or adversely impact or threaten public health or <br /> safety? YES � safety? YES NO <br /> is the svstem failina? (a yes answer is a failing system) Is the svstem failina? (a yes answer is a failing system) <br /> -Less than TWO feet of vertical separation between -Less than THREE feet of vertical separation between <br /> system bottom and saturated sofl or bedrock? NO system bottom and saturated soil or bedrock? YES NO <br /> -A seepage pit,cesspool, drywell, or leaching pit? NO -A seepage pit, cesspool, drywell, or leaching pit? YES NO <br /> Is the svstem non-comaliant? Is the svstem non-cort�atiant? <br /> - Is the system regulated under a monitoring plan or - ts the system regulated under a monitoring plan or <br /> operating permit? (if no,go to page 2) YES � �perating permit? (if no,go to page 2) YES NO <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, tha system is non-complying) (It no, the system is non-complyingJ <br /> -Does the m�nitoring indicate that the systern meets - Does the monitoring indicate that the system meets <br /> performance expectations? � YES NO performance expectations? YES NO <br /> (If no, the system is non-compiying) (1f no, the system is non-complying) <br /> Page 1 of 2 wq-wwists4.31 <br /> , ___ � . .. .,,,,., ni�nroamc usor e9� �90 90 6i i�C <br />