|
11/95/2016 06:47 7634975011 SPTESTINGINC PAGE 93169
<br /> i
<br /> ,,� . �
<br /> : ,�. y . ;: ,
<br /> Mir,nesota Pallu�ior� COCY�p�1�nGC InSpE'Ct10�1 ��rl'�1 �
<br /> ���,ff�;.;;;�'. Contrnl Ac�ency �xps�pnc� Subsurface Sewage Treatment Systems (S$TS) �
<br /> 5Za LaFayett�Road Norsh
<br /> SC Paul,MN 55155-4194 Doc Type:Complianca anal F�fbrvemen!
<br /> Instructions On page B
<br /> �Surrtmary Formi (Completed fonn must be submitted to the local unit of govemment within 15 days.)
<br /> �
<br /> Parcel number: __ I
<br /> System status: �Compllarrt [] fVoncompliaM For I.ocal Tracking Purposes: �+� ��
<br /> (based�n alf compliance requirements)
<br /> Properky Information ����
<br /> Properly owner name(s): �_����,��� PropeNy owner phona: „(m,S„1,�_�.�=0�.$�d �
<br /> Properky add�ess: _,'�`�6.5�_��?�`?..��►'.`,�::`��4^ M.t�'�...,L��i1.1._.�.Q,''�. ,.,_�
<br /> Property owner address(if different}:
<br /> _____.._____.....:...,.,.,....._..�..,...........___._ ...:. i
<br /> County,1a��'(��� Permliang authorlty: _.L.�'(."(..,.0_�!__G�'�4.j.l�.----- , "I
<br /> Date sy�ttem cansUucted: 1 a-�l- `14� Reason for ins�x�:�¢o�-� �(4�9�g�G�C�. �
<br /> System Descr�ption . '
<br /> Briefsystemdescription: .�_1lT���l.�`�'�C'�1�l��V�`�,�„/odee�,'P�+M1R �t:p'!"'i�.��rW1oa,F'�.�ru�,c��v�s�;
<br /> local permit number: ___..„r , „ ,, yy 1�.,, ,_, Number of bedl'oome: � Design flow rate: . . _y.�V y__�j
<br /> �
<br /> Is the system: i
<br /> In Shoreiand a�ea? Q Yes � No In Weflhead Protoction Ar�a? []Yes �No
<br /> A�U.S. F_nvironmental Proteciion Sys#om senring a Minnesota Oepartment
<br /> Agency(FPA)Class V Injectlon Well?�]Yes � No of Meath(MDW)licensed facility? ❑Yes �No
<br /> 1
<br /> COIY1p�1811Ce Sfia�US(Based on stat�r�equinements—addfflonaJ lacal nequirements mey also epply.) '
<br /> 8ased on the infortnaUon ggthered and reported on aitaohed forma, tlte compllence status of this systam is(check one): �
<br /> �Certificate of Compllance—valld untll(3 years hnm dats of repprfJ; �
<br /> Q Nobce of Noncompliance-�or�lancomplia►►t systems; I
<br /> The reason for noncoinpliance is: _ _.......,,�,..,..,...,.,..:._.,._..� _ .,..�-
<br /> 7his noncompllant system Is clas�lfled as(check one belaer):
<br /> ❑Imminent threat to publ�health S safety [� Failing ta prolect ground water ❑ Noi in compliance with operating permit �
<br /> Certific�tion �
<br /> 1 heneby certilj�thet all thR neccassary info�mallon has been gathered lo dete►mine fhe compllance sfsfus df fhis system.No
<br /> deferminafion of fuh,re syst�m pPrformance has been nor can be m�de due to unknown condibons durina system constr�uctia�,
<br /> p�ssiblc�a6use of the syslem,lnedequale maintenance, or fu(u�weter usage. �
<br /> Name: ^ �?�,f�,� ,�, �pj����,��a Cettifiaaiion number. _ (o�,�_____,_
<br /> Buslness Ilcense name and number: 5�'�' -i'��5���.lv �i.1 C , 1..►�,�,�3�___p����'3�y�r,���, ur �
<br /> Name of local unit of govemme�t: ., ,�___._�,_,�_„. ..r__._.... ..,._._�_ .
<br /> Signature: 1�� �. _ ._w_ _� Date: 1 1 .
<br /> 3 -ad�_..--
<br /> Required Atxachments ,
<br /> � Hydraulic Performance �Tanlc Integrity [� Operating Permit Form('if applicable) I
<br /> � Soil Boring Logs Sail Seperation ;
<br /> � System drawing/As-built dr'awing []Any(ocal requlrements that are difFerent from what is required on this form ;
<br /> ❑Other i�ormation(list): �� T,,, . �
<br /> .. ,
<br /> Upgrade Requiremen�(derived from�nn. 5tat.§i 15 55J M lmmlrrenf thr�t to pubUc health snd s�i�ly(11PHS)must be upgradad,
<br /> .repleCed,or fts use discondnu�d utn"thln ten mor�s of�ceipt of d�ls na(Ica or WlN1In 9 all0lfer period if requi►ed by locel oniinance_If Ihe syst�m Is
<br /> falf/ng Io pro�oct g►vund wafar,tNe aystem mual be upqreded.�ap/aQed,or,7s use discontinued wlfhln Iha tlme required by locaf oMinnnr�, If An
<br /> existutg system is not fa►1ing as d�linad/n law,and has at least Mro haot oP desfgn so;l sapsrelion,tAen the sysfem need not be upgradBd,reN.alred, � �
<br /> rep/acod,orlts use dlsconGnueal,nolwltllafahding ony Iocal ordinance d�atls nrore SMCt Thls prnwsia��s not apply to systems In ahaeland
<br /> eroas, Wellheed Pml�cflqn Areea,or fhoae used In connec8an wIH�food,beverage,and Mdging establishments as deA�ed In l�w. '
<br />
|