Laserfiche WebLink
~DATE OF INSPECTION: ~ <br />· REASON FOR INSPECTION <br />I))' Bcdr°°m addlti°nVarianc~ <br /> ( } Complaint <br />I~)Propcrty Tramfer {buyer or seller) <br /> <br />Minnesota Pollution Control Agency (MPcA) <br />Inspection Form for Existing Septic Systems <br /> <br /> Property Owner.(s) ~ o r'; ~' ~f6e/ Telephone (~Z) <br /> SiteAddress, ~ i/lTl~ AM Ci~ <br /> Zip Code CounW ~a~ <br /> Fire No. To.ship Name ~' <br /> Is system o~ned up~ Y ' N Full P~ ContractorRns~ller name: <br /> Towmhlp Range Section Qua~e~ <br /> <br /> Yes, ho~ o~n? : · · ~or what m~n: ~oufin:ly 0 b~m:nt b~kupO slugg~h plumbing 00~¢r < ...... ' ............. <br /> <br />~Vater uslng appliances:~o~:s w~r ~hw~h:r 0 O~age d~posfl OWhifl~l ba~ 0 W~r ~nditioning Unit ~lf~l:~ing humidifier <br /> <br />iheckappropriate sewer system component and locatiOn on site sketch on back of form). <br /> indicate <br /> ,T~nk (s): Tank(s) Material.: <br /> <br /> ~tic tank __ Fiberglass <br /> __ Aerobic tank __ Plastic <br />tPump tank __ Metal <br /> Holding tank ,~ .Concrete <br /> Other ' ' Other <br /> <br />I ank(s) Size: / 2.0"0 gals <br /> <br />· ICOMPLI~NCE INSPECTION* <br />Is there or has there ever bccn any evidence of: Discharge of sewage to thc ground surface? <br /> ischargc of sewage to a surface water'/' <br /> seepage pit, drywcll, cesspool or lcac .hing pit? ' <br /> Less than three fcct of vcrtkal separation I~twccn th:c soil t~catmcnt system <br />i, oRom and saturated soil or bedrock? <br />;cwagc backup into dwelling or Ohh~r cstablis .hmc~{ presently occurring?. <br /> Jituations with thc potential to immediately and adversely impact or threaten <br /> <br /> Soll Treatment System: <br /> __ rock trench <br /> __ gravelless trench <br /> chamber trench <br /> ,~ seepage bcd <br /> _ mound <br /> _ at-grade <br />Soil treatment area size(s): /~,~ o <br /> <br /> Other: <br />__ alternative system (identify type) <br />__ experimental, system (identify t~e) <br />__ other (identify type) <br /> <br />.sq. ft. <br /> <br />f <br /> <br /> public health or safety? YES <br />I'if YES answered for of the above the is Minn. K. ch. ?0g0.0060. <br /> Was <br /> questions, <br /> system <br /> failing <br /> according <br /> to <br /> if well setbacks are violated, a potential imminent threat to public health or safety may exist) <br /> i <br /> <br /> Basgd on the compliance inspect|on'to'adhered nbo,,~e'thesystem'statiis is <br /> <br /> I hereby'certify ts a state of Minnemta lieen.~:l Inspector, Designer I or Qualified Employee that my observation-~ recorded on this form are ~ccurate <br />fsaOf the date at thc top of this form for the ~ite stated ~bov¢. I hereby certify that ~11 inspection work was completed according to npplicable <br />quirements. No determination of futura hydraulic performance e~n be made due to unknown condition~ dudng system eonst, mction, future water <br />ge over the life of the ~stem, ~bu.~ of the system, and/or inadequate maintenance ~II of whkh will ~dver~el~ affect the life of the ~7~tem. <br /> <br />inspector's name~/c~ ~h~ t.._ ',,J~~ {p~int) Phone No.(:v& )~.~l~-ff/~ ~ License ~nd/or Regbtrati{~n Number /~ 7~.- <br /> <br />t <br /> <br /> <br />