‘Township Environmental Health Services Metro: (763) 389-3487 Toll 800-851-3383 Fax: (763) 389-9587» Email: jbraun@northle.com COMPLIANCE INSPECTION For Existing Septic Systems Required attachments: — [_]Complignce inspection [“ISite drawing [IMPCA Inspection form []Pumping Certificate © This Certificate is invalid without required attachments Inspection Date REASON FOR INSPECTION Building Permit Property Transfer Property Owner ‘Variance Other. Site Address Parcs! Number Time am/pm — Temperature: F WEATHER CONDITION GROUND CONDITIONS: ‘GROUND COVER: (clear Cain Dory = Cywer (Grass []wWooded (Cicioudy (1Snow Didamp [Frozen /Snow-covered [JBrush [JOther. ‘System in Shoreland Area? [] Yes L] No ‘Must verity with Rice County Planning & Zoning Water Body Name. Setback ft All Wells within 100ft of sytem Well Type: Distance totank__f Distance to Soll Treatment Area___ft ‘Well Type: Distance to tank ft Distance to Soll Treatment Area ft TANK(S): ‘SOIL TREATMENT: Sizo of Soll Treatment Area Clseptic Tank gallons iRock Trench Lineal feet two compartments Gravelless Trench Osa. t |Pump Tank gallons AtGrade D reduction eppticable Holding Tank’ gations nd SYSTEM TYPE: |Seepage Bed |Standard Cichamber DArtificiel Drainage (separate form required) ternative Clother Bictuster OPre-Treatment Device LiPerformance System Operating Permit # ‘+tmonitoring records required SOILS: Depth of soil trestment area in ——_Depth of sand/mound in *Weppleabis Depth to the restricting layer fein Cstanding water [soll redox []bedrock |Separation Distance = in. STATUS OF SYSTEM: In conclusion of the compliance inspection conducted above, the status of the septic system is: In accordance with Minnesota Rules, Chapter 7080 criteria for existing individual sewage treatment systems, therefore, This document is a Comments: An imminent Health ThreatEXISTING SEWAGE TREATMENT SYSTEM COMPLIANCE INSPECTION: DURING THIS INSPECTIONON__|__/. WAS EVIDENCE OF ANY OF THE FOLLOWING OBSERVED? “Surface discharge of sewage effluent to ground or water body?" []¥es [INo *Moist, wet, spongy, or overloaded soil treatment area?* (yes [INo *Evidence of a seepage pit, drywell, cesspool? Des Backup of sewage reported by owner or authorized agent? Clves Less than THREE feet of vertical separation between the soil treatment system bottom and ‘seasonally saturated soil(redox) or bedrock? CYes CINe ot Before 1996 In non-shoreland areas, two feot of seperation= “In Compliance” for systems constructed before *Soil treatment system is located /N permanent water table?* es, A INo Any part of the system that does not meet required wall setback? ‘esINo ‘Septic/pump tank that is not watertight? (per Pumping Certificate) [jYes[_JNo Drainback from soil treatment system? (Per Pumping Certificate) [_JYes[_]No *iPHT=Imminent Public Health Threat If"YES" was answered to any of the above, please explain below: For BUILDING PERMIT application only: CINot Applicable Does the existing septic system meet minimum setbacks to ALL surrounding wells? C]YES [INO EXISTING: PROPOSED: eee Number of Bedrooms: 7 im Ww Type Home: | 7 WwW ‘apd Flow: pd sqft Soil Treatment Area: sqft jarbage Disposal: fos Garbage Disposal: Estimated Soif Sizing Factor ‘The existing system [] 1S / [1] 1S NOT sized properly for the proposed addition. Comments / corrective action: is with ARTIFICIAL DRAIN, (Not Applicable Is the dedicated surface outlet flowing? the fj No Fecal Colform Bacteria sample collected? “|_]Yes Chao If yes, attach laboratory analysis. Piezometers installed? Ces CINo tyes, indeate location(s) on site plan Has Monitoring been performed Ces [No Results Acceptable []¥es [JNo []Pending CERTIFICATION: Ihereby certify with my signature as a State of Minnesota licensed Designer 1 Professional that my observations recorded ‘on this form are accurate as of the date of inspection. No determination of future hydraulic performance can be made due to unknown conditions, future water usage over the life of the system, abuse of the system, and/or inadequate maintenance, all of which will adversely affect the life of the system. Compliance inspection Evaluator Certification Number. ‘Presse Print) Signature Phone Number. Date, CERTIFICATE MUST BE SUBMITTED TO TOWNSHIP ENVIRONMENTAL SERVICES WITHIN 30 DAYS OF INSPECTION DATE. Send to: Township Environmental Health 2428-115" Aveenue — Princeton, MN. 55371