|
07/19/2611 21:33 7634975011 �� PTESTINGINC PAGE 02/09
<br /> . � `\
<br /> �C� � �' .
<br /> ,
<br /> Minnesota Pollution �� pliance inspe�taon Form
<br /> A'�``�'�::•-�__- Control Agenty
<br /> ....- E u uirface S�wage Treatmen�t Sys�ems (SSTS)
<br /> 520 Lafayette Roac!North
<br /> 5t.Paul,MN 55155-419+1 Doc rype�Complianco and��forcement
<br /> 9nstructions on paga 6
<br /> Summary �o�rm (Completed form must be submitted to the locai unit of government within 15 days.)
<br /> Parcel number. ,_„^ .,.___,__ _..�
<br /> System status: For Loc�l Tracking Purposc�s:�
<br /> �Compliant [] Noncomp►iant
<br /> (based on all comp►iance requlrements)
<br /> Property Information
<br /> Property owner name(s): �G a���\�I► �.I.�t�?�I Property owner phone: ��'t,.'7d,C) -�'?��
<br /> Property address: a,�-1��1.1�r ta'� L�a� rG. �v�C, _. _
<br /> Property owner address(if dlffarant): _ __„�_�,_.,..,�
<br /> Cauniy� t-1�i�-t�1�k�1 Permitting authority: ,,.,����p�b�O�c?
<br /> D�te system constructed; al O 0 I _ Reaeon for inspection; �D�p��(^�P�Y3�!IS _��_'_ .
<br /> System Desc�ription ��►a�,.�,� �►�����.� l�."¢o��
<br /> B�ief system description: o-�loon�l,S��-�►e� �t�+���^'� + 3q� �-+a�y�'(i o'�s���►_�'P-v�v�w�-�� P�'P�• �.
<br /> Local permit number: Number of bedrooms: 5� Design i�low rc�te: 7 c7 .�
<br /> Is tho system:
<br /> In Shoreland area? []Yes � No In Wellhead Protection Area? ❑Yes �1 No
<br /> An U_S_ Envlronm�ntal Protection System serving a Minnesota Department
<br /> Agency(EPA) Class V Injedion Well?�Yes I� No of I-leath (MDH)licensed facility? ❑Yes � No
<br /> C0111p1i811C2 StdtUS(eased on stete r�quirements-additionel local requirement;s may alsa app/y.)
<br /> Besed on the infoRnatian gath�red and reported on atkached forms,the compllance status of this system is(chock one):
<br /> �Certificate of Compliance-valld until(3 years from date af Oaport)�
<br /> [� IVotice of Noncomplianne-For Nvncompliant syst�ems;
<br /> The reason for noncompllance is: ...,...Y.,_�.,
<br /> This noncompl9ant system is classified as(check o�e balow):
<br /> ❑ Imminent threat to public health&safety ❑ Failing t�protect ground water ❑ Not in compli�nCe with operating permit
<br /> Certif9catian
<br /> 1 her�by ceriify that all the necessary informatlon has been gafhered tn detennine the compllance status vf this sysfem.No
<br /> dete►m�nBGvn of futur�system perfo►mance has been nor can he made due to unknown condiflons during systom construction,
<br /> passible abuse of the system, /nedequate mainfenance, or future water usage.
<br /> Neme: �t'%V _.,,,,,;�_sr�.�t�5 Certification numbe�: (0�7
<br /> Buslness Ilcense name and number: S-4 -���_I�LJLz_��C . �.�L' � �` 39'�-�N�'?to3-`�`D7� �S���c+ or
<br /> Name of local unit of government: . �__ ____ __�.r._,
<br /> Signature: _ Date: _,___
<br /> Required At�achments
<br /> � Hydraulic Performance �Tank In�tegrity [] Operating Permi�Form (ff applicable)
<br /> � Soil Bonng Logs � �oil Separation
<br /> (� System drawing/As-bu(It drawing ❑ Any local requirements that are different from what Is required on this foRn
<br /> ❑ Other inforhtation (list): ,,,,_ �.
<br /> Upgrade Rpquitements (derlved from Minn. Stat.§115.55J An lmmJnent fhr9et to publlc health and satety(ITPHS)musr Ge upgreded.
<br /> .raplac�d,or its use discontinued wlthln ten months of recelpt of thls nofice.or wifhin 9 shorterper�ad if required by local ordlnance.IF the system is
<br /> failin.q to protect ground water, the sy&tem must bo upgraded, �placed,orlls uso disconfinued wiHtin Ihe Bme required byloctal ordin�+nce.!f en
<br /> existing syst�m Is not falling�s defined in lew,end has at IeasP!wo feet of of�islgn so�7 separation, then the system noed not be upgraded,rapell�d,
<br /> repiaced,orits use discontJnued,notwlthstanding any local ordinancQ that is more str�et. Thls provisia��does not apply to systems In shoreland
<br /> areas, We1lhEad Profe�tlon Areas,or tHose used!n connection with food,l�eve►'ag�, and lodging esteblfshments as defined in lew.
<br />
|