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Rug,09 �,�8 �1 : l lp Rndy Kleindl [9521 -442-9281 p. 2 M �f � inn�sotaPoilution Compliance Inspection Form ontrol Agency 0 Lafayette Road Norch Ex�sting Subsurface Sewage Treatment Systems (SSTS) .Paul,MN 55155-4194 Instructions on page 7 Parcel num er: For Local Tracking Purposes: System stat s: ❑Compliant ❑ Noncompliant (based on a compliance requirements) Summa Form Propert Information Property wner name(s): Dean Patterson ._. .. _.. ._ Property ddress: _ 2058 Shoreline Drive . _ _ .. .— Property wners address(if different): County: enne in Property owner phone: 612-328-1173 Permitting authority: .�r _ _ Date syst rn constructed: 1984 Reason for inspection: homeowner request System escription erief syst m description: �� T�t��'S , I'�CK �.°✓�C��.S _...... Local pe it number: Number of bedrooms: 5 Design flow rate: . Is the sy tem: In Shor land area? �Yes ❑ No In Wellhead Protection Area? ❑Yes �No An U.S Environmental Protection System serving a Minnesota Department Agen (EPA)Class V Injection Well?0 Yes �(No of Heath(MDH) licensed faciliry? ❑Yes J�No Complia Ce StdtUS(Based on state requirements–additional local requirements may also apply.) Based on the information gathered and reported on attached forms,the compliance status of this system is(check one): �Certifi te of Cornpliance–valid until(3 years from date of r�port): ❑ Noti of fVoncompliance-For Noncompliant systems: Th reason for noncompliance is: � �— Thi noncompliant system is classified as(check one below): ❑ minent threat to public health&safety ❑Failing to protect ground water ❑ Not in compliance with operating permit C@ftiflC t10� (Completed form must be submitted to the local unit of governmerrt within 15 days.) I hereby ertify that a!1 the necessary rnformation has been gathened to determine fhe compliance status oi this system. No determin tion of future system performance hes been nor can be made due fo unknown condifions during system construcfion, possible buse of the system,inadequate maintenance, o�future water usage. Name: Andrew Kleindl ^ _ Certification number: 2926 . Busines license name and number: Jim's Excavating, LLC . _ or Name of local unit of govemrnent: — — • - - Signatur : ,��[�,.,_--� Date: Au9ust 9,2008 Require Attachments Inspector Complete: This Inspection Report is�pages long. Check C mpliance fo�ms altached: �Hydraulic Performance �Tank lntegrity �oil Separation ❑Operating Pertnit Form(if applica le) �System drawinglAs-built drawing ❑An assessment of any local requirernents that are different from what is required on this forrn So Boring Logs ❑Abandonment form(if appropriate) ❑Other information(list); Upg� dB RequlT2m 81115(de�ved from Mlnn. StaL§115,55J An lmminent threat to public health and safety(lTPHS)must be upgraded,replaced,or its use iscond'nued within ten months ol receipt o/this noGce or wifhin a shorte�period if required by local ordinance.IT the syslem is failing to protect ground water, e system must be upgraded,replaced,or its use disconUnued within the time requlred by foca!ordinance.!f an exlsting system is not tailing as de�ned rn law,a has af least two feef of design soi/separaL'on.�hen the system need not be upgraded,repaired,replaced,or its use dlscontirtued,notwithstanding any local o inance fhat is more sVict. This provision does not apply to systems in shoreJand areas,Wellhead Protec6on Areas,or those used in connecfion wifh lood, bevera e,and lodging establishments as deh'ned in law. . . ,. Compliance Inspection Form for Existing SSTS