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05/09/2012 14:29 9528733112 ( 1"' PAGE 01105 ,Minnesota Pollution ,� -/ Compliance Inspection Form Control Agency Existing Subsurface Sewageireatment Systems (SSTS) 52l)Lafayette Road North St.Paul,MN 55155-4194 Instructions on pale For Local Tracking Purposes Parcel number. System status: Compliant 0 Noncompliant ph (based on all co nce requirements) Summary Form Property Information , - Property owner name(s): L',/�(f 1 s 6---cf11 _ .._.. L./Property address: 4— / I rr` L.'A — j40 -,___-- ....., __.. Property ow er's address Of different): �o�} �1 County: /,J21fi A. Pro a owner phone: ,e `( 8 �T$Y er Itting authority: ____,._ . - Date system cons rutted: 5 Reason for inspection: . .. . .. ... System Description ^��) /y� Brief system description: & �.Tl22 Sepik- S k) /_'1- �4 Local permit number: ',r� ` Number of bedrooms: Design flow rate: V� •__,__ Is the system: In Shoreland area? YLYes Q No In Wellhead Protection Area? ❑ Yes No An U.S. Environmental ProtecUon System serving a Minnesota Department Agency (EPA) Class V Injection Well?❑ Yes po of Heath (MDH) licensed facility? ❑ Yes No Compliance Status(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) Certificate of Compliance-valid until (3 years from date of report): ---- ❑ Notice of Noncompliance- For Noncompliant systems: The reason for noncompliance is: -- - This noncompliant system Is classified as (check one below): Q Imminent threat to public health&safety ❑ Failing to protect ground water ❑ Not in compliance with operatIny permit Certification (Completed form must be submitted to the local unit of government within 15 days,) I hereby certify that all the necessary information has been gathered to determine the compliance status of this sysiem NO determination of future system performance has been nor can be made due to unknown conditions during system consrrucl,oll possible abuse of the system, Inadequate maintenance, or future water usage. Name: -_ ��k �`� — Certification number: 9\\( �._..._ - Business license name and number: %.. _`\L- _ af 00 tea--- °r Name of local uni '/overn p- , - �I � Aw Date: 5/ Signature: ��,r,, i.�. �.l Required attachments Inspector Complete: This Inspection Report Is pages long. Check comp) ce forms attached: Hydraulic Performance ark Integrity .oil Separation E] Operating Permit Form i.f applicable) System drawing/As-built drawing ❑An assessment of any local requirements that are different from what is reGu,reo onlets form ❑ Soi B ng Logs ❑Abandonment form (if appropriate) ❑ Other information (IrSt): Upgrade Requirements (derived from Minn. Sial. §•115.55)An imminent threat to public health and safety((TPHS)must be upgraded,rcaiaccc. its use discontinued within len months of receipt of this notice or within a shorter period if required by local ordinance. If the system is le trng to elated;morn^ water,the System must be upgraded,replaced.orbs use discontinued within the lime required by local ordinance.If an existing system rs not fawn;g s ce^^mac len,and nas at least two feel of design soli separation. then the system need not be upgraded,repaired,replaced, or its use discontinued norwau s:anr:^y?-, local ordinance(hat is more strict, This provision does not apply to systems in shoretand areas, wellhead Protection Areas,or Mose used' it cosine:•,Jrr .,+ oeverago. and lodging establishments as defined In law. rmmnlinnrp lnenarrinn Fnrm fnr Fxissirt' SSTS