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03/09/2010 01:28 7634975011 SPTESTINGINC PAGE 04/13
<br /> Min.l,esoka Pollution Compliance
<br /> Inspection
<br /> Control p n Form
<br /> to
<br /> Existing Subsurface Sewage Treatment Systems (SSTS)
<br /> 520 Lafayette Road North
<br /> S .Paul,MN 55155-9194
<br /> Doc Type;Compliance and Enforcement
<br /> Instructions on page 7
<br /> Summary Form (Completed form must be submitted to the local unit of government within 15 days.)
<br /> Parcel number:
<br /> System status: 0 Compliant 0 Noncompliant For Local Tracking Purposes; ____ ——
<br /> •
<br /> (based on all compliance requirements)
<br /> 1
<br /> Property Information — -- --, I
<br /> Properly owner name(s): 1� 4 :�;
<br /> _00)(►'►0 . . Property owner phone: 10_,(). .- y�4
<br /> - Zy4Property address: — tLC
<br /> Property owner address(if dlrterenl); —i_•� O O —
<br /> County:_..y�r1•-L+� �) � permitting aulhori —'— _—
<br /> Date system constructed: ` tY ��'�'{ th prp —_
<br /> 1-)0 - q -— Reason for inspection: — -
<br /> System Description -
<br /> Brief system description: ,A•�0dtrl_y_�.,(01.4w i0d0 ��n
<br /> Local permit'number: � �dZ7 �'�����'� u��`e' �''��h /ctrl gS �rpc,01,
<br /> ,_ Number of bedrooms: „ t}:— Design flow rate; .(a p p
<br /> Is the system: —
<br /> In Shoreland area? 0 Yes i:a? No in Wellhead Protection Area?
<br /> An U.S. Environmental Protection ❑ Yes i� No
<br /> Agency(EPA)Class V Injection Well? System serving a Minnesota Department
<br /> I0 Yes ll No of Heath(MDI-I)licensed facility?
<br /> ❑ Yes si Na
<br /> Compliance Status (Based on slate requlrenients-additional local requirements may also apply.)
<br /> Based on the Information gathered and reported on attached forms, the compliance status of this system is(check one):
<br /> ❑ Certificate of Compliance-valid until (3 years from dale of report): _
<br /> [111 Notice of Noncompliance-For Noncompliant systems ••
<br /> The reason for honrvmpllance ls': I e V a t j
<br /> This noncompliant system Is classified as Icheck one below101OkOS ^
<br /> ):
<br /> 0 Imminent threat to public health&safety LJ)Failing to protect ground water 0 Not in compliance with operating permit.
<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 /> Name: .., -. 41.,\_.•13. , SGN), ..,5,,� — Certification number: G:7?,I _
<br /> Business license name and number: S-I' -CO, b —
<br /> Name of local unit ''�)3a�. 11.1 \- _4�`�'L"L.. `1t4r-45,7-IAA.,or
<br /> of government:
<br /> nt: _ �\��• h-
<br /> 5ignalure _ 1 , , �,,,—�----
<br /> ..—_ �.. Data: 3- 56,-P,.0)0
<br /> Required Attachments "
<br /> P'I Hydraulic PerformanceTank Integrity
<br /> E► Soil Boring Logs Soil Separation Operating Permit Form (if applicable)
<br /> tii51 System drawing/As-built drawing 0 Any local requirements that are different from what is required on this form
<br /> WI Other information (list): (�S,
<br /> Upgrade Requirements (derived from Minn. Stat. § 115.65)An Imminent throat to public health and safely(ITFHS)must be upgraded,
<br /> replaced,or its use discontinued within ten months of receipt of this notice or within a shorter period If required by local ordinance.If the system is
<br /> failing to prefect ground weler,the system must be upgraded,replaced,or its use discontinued within the.time required by local ordinance.If an
<br /> existing system Is not falling as defined In law,and lies at least Iwo feet of design soil separation,Then the system hood not be upgraded,repaired,
<br /> replaced.or its use discontinued,notwithstanding any local ordinance that la more strict. This provision does not apply to systems In shoreland
<br /> areas, Wellhead Protection Areas,or those used In connection with food,beverage, and lodging establishments as defined in law.
<br /> www,pca.state.mn,u5 • 651-296.631111 1 800"657.3864 4 TTY 651.282.5332 or 800-657.3%4 ; i•. .��_
<br /> wq•wwists4.31 • 4110109 Available in alternative formats
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