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° �� . M�nn�sota Po��ution Compliance Inspection Form �w Control Agency , 520 L'fayette Road North Existing 3u6surface Sewage Treatment Systems (SSTS) 'I S�Pe�l,MN 55155-4194 Instructions on page 7 I Parcel number. �, For Local Tracking Purposes: Sy�tem status ❑ Compliant � Noncompliant (ba�sed on ail cornpliance requi►sments) S4mmary Fbrm � Property Infbrmation Rroperty owner name(s): SS.o-C� V� L1G�'�M��1 . Property address: a.b 4�S '��l�.L"{ S�• _ b'� �1 c� Property owner's address(if different): County: �.1��,�,�p��,� Property owner phone: (o�Z-a�q -'�a�! Permitting authority: p��Q , D�te system constructed: J�j�� Reason for inspection: �Q�(p��A-�¢. '� System Description ' �, Brief system description: a-10�9��«1 s�r.��c.. �A��-s�i ua��.,( Qa��,.+�� ,,�o,,»,�, �v�x ��or�$fdh Local permit number: Number of bedrooms: �_ Design flow rate: (0 00 Is the system: In Shoreland�rea? ❑Yes �No In Welihead Protection Area? ❑Yes � No An U.S. Environmental Protection System serving a Minnesota Department Agency(EPA)Class V Injection Well?0 Yes �No of Heath(MDH)licensed facility? ❑Yes � No C0111P�idllCe $tatUS(Based on state requirements-additionai local requirements may aiso apply.) Based on the information gathered and reported on attached forms,the compliance status of thissystem is(check one): ❑Certificate of Compliance-valid until(3 years trom date of report): �Notice of Noncompliance-For Noncompliant systems: The reason for noncompliance is: 5�.1'i�'A-L��V A�T '�fjUl�'k,�p. This noncompliant system is classified as(check one below): . Imminent threat to public health&safety ❑Failing to protect ground water ❑ Not in compliance with operating permit C@CtIflCdttOtl (�ompleted form must be submitted to the local unit of government within 15 days.) 1 hereby certify ti�at all the necessary infonnation has been gathered to detenr►ine the compliance status of this system. No determination of future sysfem perto►mance has been nor can be made due to unknown conditions du�ng sysfem construction, possible abuse of the system, inadequate maintenance, or future wafer usage. Name: �r'`�—►,)�� (�-1�r7,�ry �S Certification number: (o a.� Business license name and number: 'S -`� -��-rti�l.� ��i L'!ti�e.�4��,. 1.�c2 7�'��IoG, or Name of local unit of govemment: Signature: J�� •�j�ti Date: /U -4f --p c,s Required Attachments Inspector Complete:This Inspection Report is pages long. Check complianCe forms attached: �Hydraulic Performance ❑Tank Integrity ■Soil Separation ❑Operating Permit Form(if applicable) �System drawing/As-bullt drawing ❑An assessment of any local requirements that are different from what is required on this form ■Soil Boring Logs ❑Abandonment fonn(if approprlate) �Other informatfon(Ilst):!a� pfGS1b�. Upgrade Requirements(derived from Minn.StaL§115.55)An Jmm�nent threat to publtc health and safety(ITPHS)must be upgraded,rep�aced,or !fs use dlscontlnue�l wlthln ten months o/rece/pf of thJs notice or withln e shorter perlod!/requlred by local ordinance.//fhe system is falling to protect ground wafer,the system must be upgradetl,replaced,Or Ns use dlsconNnued withln the tlme requfred 6yloca/ordlnance.I/an exlsting system/s not falling as defined In /aw,and has at least two feet of design soH seperatlon,then the system need not be upgr$ded,repalred,ieplaced,orlls use discontlnued,nofwNhstanding any bcef ordinance thaf/s more sMct. Thls provlslon does not apply to systems in shore/and areas,We//head Proteetbn Areas,or those used!n connect/on with 1ood, bevorage,and lodging establJshmenfs as deiJned In law. wq-wwists4-31 Compliance Inspection Form for Existing SSTS 4/1/08