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5 i <br /> � ) , <br /> 3"'�t$�"2: <br /> ��;�;'�-� 1Vlinnesota Pt�llution Compliance ins ection Form <br /> .�,r,.:r..4 � <br /> N% �� <br /> .Y Control�genty <br /> szo t.afayetce�.oaci North ��gting Subsurface Sewage '�reatment Systems� <br /> s�.�au�,MN 55155-4194 (SSTS) <br /> 1Joc Type:Compliance and EnforCement <br /> Instructions: Inspection results based on Minnesota Poilution 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(mm/dd/yy.yy): <br /> ❑ Compliant— Certificate of Compliance ❑ Noncompliant— Notice of Noncompliance <br /> (Valid for 3 years from report date, unless shorter 6me (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�i.?)-Imminent threat to public health and safety <br /> ❑Tank Integrity(Compliance Component #2)-Failing 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 /> r� .,.,_;_..; <br /> u �N��Q����y�c�„��ti�n�r�iiu�iny pian requireinenis(i;ump�iance�omponent #5j-Noncomplranr <br /> Property Information Parcel ID#or Sec�fwp/Range: <br /> Property address: 3��0 - �'D, 1e.Q •�p Reason for inspection: �,�! - <br /> � <br /> Property owner: Owner's phone: <br /> or <br /> Owner's representative: Representative phone: <br /> Local regulatory authority: C� � d Q iQ0�o Regulatory authority p one: <br /> Brief system description: �-/p0 r/ 9 �� j�w�c� � �s� ��f'yJ1�e...- - /�D��('(�� ���(�� <br /> Comments or recommendations: <br /> Certification <br /> I hereby certify that alI the necessary information has been gathered to determine the compliance status of this sysfem. 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: ,LE11.9 � �y.��,� Certification number: 7S6 <br /> Business name: /y[E ��L o 4aL f � 1',�,f ��,�„� r a� License number: �L/ <br /> Inspector signatur . Phone number: �C�- {/7�- /7,C-o <br /> Necessary or Locatty Required Attachments <br /> �Soil boring logs [���tcMAs-built�drawing ❑Forms per local ordinance <br /> ❑Other information(list): �T � �� <br />