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70:2638757 <br />MRY-9-2006 08:16 FROM:MERWIN & ASSOCIRTES 7638560901 + T-4Z0 P 001/003 F-P4g <br />yAY-Od-2006 16:12 Flt0il4-CALL CENrR <br />• - 2/29/02 yVaterj4Yastawater1Sf5913 <br />C©mp(iance Inspection Forn1 for Exisfiins rotnnesota Poltutiart <br />,~ Individual SewageTreatmenC SysCems CcntrotAgeney <br />CvmDJouot) olUUe /orm RdIUJs the minlmeJ teCuJremeMs olMGn~lwlSws ~eo} ol~nca~egvUemarnts ~ortbedrOm eddlgo~~ Pteaso refs <br />& ~~~~~ <br />Date ofln~pection, `=~-•,~-~.,,.-~ ReasonforlnspectJan; ~~--~---- <br />~~• ~• . >' Telephone ( ).;~~rfL. ==c~~ <br />Property owner{sj •~=~- ~ ~~ ~ <br />)ephon4 ~ ~~ <br />Person requestlng lnspaet}o~i _ City /'rJ~ep- XJp Code G <br />SitaAddress ~ Township '• ' <br />Pire No.~ Parcel No. ~ County <br />Legal Desalptton y £ ~r <br />LoalRegulaWryA ti~nrrN C ~~]L <br />..~ '.7 sterrtin Shvreland Area: yes system !n Wefiht3ad. <br />Dato systehi toastruded ;~ j •-+---- ~ ocat Permtt # pf arty) ~. <br />Protection Area: yey~}srysttsm serving a MA}i Ilcensed faelilty: ya~~ ~. - <br />SYseertrs bulit prior to Apr11 1, 1996 and not located in <br />` Shoreland pr Wellhead P~gteetlpn Area or 5ervinq a Food, <br />,~,..r, (,s~'~•;j •~verage or Lodging EstabUshFnpnt <br />s•tlie'sX,Qetiianiinintrientthr•eafito'a~611ch ate__tkcr <br />•.Dtschefgaol'sett^sgxtoq?49rgJpdsurfaea7 YES <br />;• Dlscharlraectstwtgge tt;dratntite or surface water~l YES <br />;,5ewa9a.-4.~!PNtt~~~1pA9? .••, •. - YES 0 <br />4Sltuathm wltq the potcntla! to, )mmedlately and • <br />adversely Intgad or thnss!en p•.rbltt: htwFth or TFS~ <br />safaty9 <br />1" fY1M.1 <br />Y t~~g~3@,pi,~attlnaT(a yes aRsrvarls a fellliigsYstem) <br />= L'eu~U!~~~~fcro`v~r~tt~(,separabop betweSn "• <br />. •Sjrstem,bptrovl•p~tiJt4?a!$-ao!! ortxdr•oeKl r ~ Yr:s O• <br />- A ~a4~P.yf~~olftl9~WJ; orlQach}rlg pit? Y~ <br />r~ ~ }ie•Ilalsn }n;•I1,~hfx •Ii0• • <br />Is, the svsfem non•ctimoliant? <br />- !a the syatom rogutatad tmdor a mon#toring plt+n or <br />opeaatnng pertntti P!•no, po ro pegs 2) YES <br />..tr~a~ <br />• !•las the fegUhttd monlloAng taken pface~ YES NO <br />(rl na ~Q al'tt~~'99n~rpM, nn81 1. <br />Ynil`~>'l•11111:1!ZNTrT./~ ri ltr~+r +t°•r` <br />• Doha tge,lnollgarLngJndfctsie thaE4he system meets <br />perfatmantevxpopialions? YES NO <br />(n no> the •ratrm p'non~omptytny) <br />stems located in Shoretaftd or Wefthead P <br />Ansas or Serv-ng a Food, eeveragtt or Lod <br />Estabtlshmsnt, or systems Buttt after <br />~, ~ ;o ~ t an trnrnt entthreat ovblichEafth <br />or safely? •(a yes answe~ts a>7 n'PHSsYsrernl <br />• Alst:hatDe of sewage L'o the ground sutfacat YEr ~9,~ <br />- plscharga of sewage to oralntlle or surrbte waters? Yom' ~~ <br />- Sewaya barkup IrKo tirteittng? YE.S 1G0 <br />• 5lfuatlon with the potentla} to tmmeetatety and • <br />adversely impact or threaten pubtlc health or <br />satety7 Ytwc :t4O <br />Ys the ~~~eM faF}Ina? (d }'ESBl1SriBt(S•d ldl/1119'SySlplt7~ <br />- Lt:ss•Oran T}f REE feet of vetUcal separatlon tielwtan <br />system bottom and saturated sotl or be4rpCk'! •YES lQt:% <br />-Aaeepage pit; cesspool, dryweR, orleaching pti ~` :~•• <br />~sthasYSter+t nan-eo_moffant? <br />- la the system regulated under a monltartng~ ~~ • • <br />operating perm!!? {Jl no, go to page 2) •• <br />Jf yes, <br />• yes the required monitoring taken place? YFS ~ NO <br />(If no, the system Js rioncorn~lyJny) <br />• Ooes thm monitofing #ndicate that the system mea~ ~ <br />peAormance expectaubna7 , <br />(lrAV; Uro sysrern !s non•e+vmptying) ~..,,- <br />~. <br />Page i oftis`• - wq=~i^rlsrsq.9l <br />1 ~ .. <br />