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• <br /> • . Minnesota Pollution Corn p <br /> ince Inspection Fernvos, Control Agency <br /> 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems <br /> St.Paul,MN 55155-4194 (SSTS) <br /> Doc Type:Compliance end Enforcement <br /> Instructions: Inspection results based on Minnesota Pollution Control Agency(MPCA) For local tracking purposes: <br /> requirements and attached forms-additional local requirements may also apply. <br /> Submit completed form to Local Unit of Government(LUG)and system owner <br /> within 15 days <br /> System Status <br /> System status on date(mmlddlyyyy): `'1-~-1` <br /> tri Compliant—Certificate of Compliance ❑ Noncompliant—Notice of Noncompliance <br /> (Valid for 3 years from report date,unless shorter time (See Upgrade Requirements on page 3) <br /> frame outlined in Local Ordinance.) <br /> Reason(s)for noncompliance(check all applicable) <br /> ❑ Impact on Public Health(Compliance Component #1)-Imminent threat to public health and safety <br /> ❑ Other Compliance Conditions(Compliance Component#3)-Imminent threat to public health and safety <br /> ❑Tank Integrity(Compliance Component #2)-Falling to protect groundwater <br /> Other Compliance Conditions(Compliance Component#3)-Failing to protect groundwater <br /> ❑Soil Separation(Compliance Component #4)-Failing to protect groundwater <br /> ❑Operating permit/monitoring plan requirements(Compliance Component #5)-Noncompliant <br /> Property Information Parcel ID#or Sec/Twp/Range: y , <br /> Property address: Lir'? CI 0 h40C,(''\ A o `. , Reason for inspection: ,cr /4 <br /> Property owner: Owner's phone: (,tip- - �c� <br /> or <br /> Owner's representative: Representative phone: <br /> Local regulatory authority: c.t-C-( 04 1,7“ <br /> Regulatory authority phone: 95; - y q _ 4 b fl o <br /> Brief system description: - a.I epeAFK,cP <br /> vq- /00 o _tV�1--% 441-Y4- ed MuComments or recommendations: ✓} Fgfi= Pow � <br /> t-s�,�.,��. <br /> Certification <br /> I hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No <br /> determination of future system performance has been nor can be made due to unknown conditions during system construction, <br /> possible abuse of the system,inadequate maintenance, or future water usage. <br /> Inspector name: 5-f�y LA‘1.-1,,A4:10 -„,. Certification number: <br /> Business name: -� � IP, License number: <br /> Inspector signature: .-.4.111,77._., Phone number: ita - <br /> '"l - 5i,to <br /> Necessary or Locally Required Attachments <br /> 153 Soil boring logs IN System/As-built drawing 0 Forms per local ordinance <br /> ❑Other information(list): <br /> www.pca.state.mn,us 651.296.6300 0 800-657-3864 o TfY 651.282.5332 or 800-657-3864 . Available in alternative formats <br /> wq-wwlsts4-31 • 1124/12 <br />