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Compliance Inspection Compliance Inspection UID # 53952
Status: In Progress
 

System Status

System status on date: System Status:

Property Information

Property Information:
None
Property Owner's Mailing Address
(if different than property address):
Owner's representative:

Impact on Public Health

System discharges sewage to
the ground surface:		 System discharges sewage to
drain tile or surface waters:		 System causes sewage backup
into dwelling or establishment:
Verification method(s): Comments/Explanation: 







	





	
Tank Integrity

	


System consists of seepage pit,
 cesspool, drywell, or leaching pit:		




Sewage tank(s) leak below their
 designed operating depth:		




 :




Verification method(s):




Comments/Explanation:








	





	
Other Compliance Conditions

	


Maintenance hole covers are damaged, cracked,
 unsecured, or appear to be structurally unsound:		




Other issues (electrical hazards, etc.) to
 immediately and adversely impact public
 health or safety:		




Explain:





System is non protective of groundwater for other
 conditions as determined by the inspector:		




Explain:








	





	
Date of Install

	


Date of install known:




Date of installation:







	





	
Soil Separation

	


Shoreland/Wellhead Protection/Food, beverage, lodging?




Drainfield has at least a two-foot vertical separation
 distance from periodically saturated soil or bedrock:		




Drainfield has at least a three-foot vertical separation
 distance from periodically saturated soil or bedrock.:		




Drainfield meets the designed vertical separation
 distance from periodically saturated soil or bedrock.:		




Verification method(s):




Comments/Explanation:





A. Bottom of distribution media:
 Decimal Feet



B. Periodically saturated soil/bedrock:
 Decimal Feet



C. System separation:
 Decimal Feet



D. Required compliance separation:
 Decimal Feet






	





	
Operating Permit and Nitrogen BMP

	


Is system operating under an Operating Permit:




Is the system required to employ Nitrogen BMP:







	





	
Comments and File Attachments

	


Comments or recommendations:





Attach Files:

    		

    

    

    
	
    

    

    
	
    Certification
    
	
    

    Inspector:


    
	
	
	
	
    None
    

    

    Please search for and choose SELF/OTHER if what you need does not appear in the list
    
    		

    

    Inspector Contact (If 'self/other' is selected from the Inspector Lookup):


    

    Inspector Email Address:


    

    

    
	
    

    

    
	
    Invoice #10419 (07/10/2024)
    
	
    

    


    
	
	Charge
	Cost
	Quantity
	Total
	

    

    
	Grand Total

    
	Total
	$0.00

    Due$0.00
    This Application has not been submitted, so you may not pay for this Invoice.
    Action: Print  
    


    
	
    

    

    

    


    

    Text:

    		

    

    File(s):

      		

      

      

      

      

      


      

      Text:

      		

      

      File(s):

        		

        

        

        

        

        


        

        Compliance Letter Type:

Who's signature should be on the letter?

Permit number to reference in "No Replace" letter:


        

        Was the letter sent?

Compliant/Non-Compliant:


        

        

        

        

        


        

        Certificate of Compliance:

          		

          

          

          

          

          


          

          Letter of Non-Compliance:

            		

            

            

            

            

            


            

		
            
		
		
            

            
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