2011 - Compliance Inspec Form - Laserfiche WebLink

Home Browse Search

Minnesota Pollution Compliance Inspection Form Control Agency 520 Lafayttte Road North Existing Subsurface Sewage Treatment Systems (SSTS) St,Paul,MN 55155-4194 ,•' Instructions on paste Parcel number: ;'( For Local Tracking Purposes System status: Compliant ❑ Noncompliant IN-)(€311 / (based on all co Alia ce requirements) Summary Form Property Information Aii Property owner name(s): �R 1� Property address: /'70 (k1.� t�rViA.- O1Lff`t. _.. __.. Property owner's address (if different): �,�i/ County: PIMA A 1\fkek-- Prop owner phone: 7..0 "Tlfp -0963 CPeermitting authority: Date system constructed: -g1 O Reason for Inspection: 5c System Description ,/ 9_ Brief system description:pf� 2 0TTQ.,.r2E6-51- Sf{} � -1-4.104S, )c0 lI ter" 14F;Tc�-t -.A/ Local permit number: - Number of bedrooms: Design flow rate: 6,a• Is the system: r In Shoreland area? Yes ❑ No In Wellhead Protection Area? ❑ Yes KNo An U.S. Environmental Protection System serving a Minnesota Department ,,/r Agency (EPA) Class V Injection Well?CI Yes So of Heath (MDH)licensed facility? El Yes e) 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); C ; ❑ Notice of Noncompliance - For Noncompliant systems: The reason for noncompliance is: - This noncompliant system Is classified as (check one below): ❑ Imminent threat to public health & safety ❑ Failing to protect ground water 0 Not in compliance with opaaraling parr( 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 system a.: determination of future system performance has been nor can be made due to unknown conditions during System cork(' ,Cr.:r: possible abuse of the system, inadequ to maintenance, or future water usage. ` Q Name: _.. C t D� Certification number: �1 69.._.. • Business license name and number tC,Q-S r\C— g5ca -..-.. or Name of local un.vi gover. ant: OF ---. -- --- . . i Signature: i . .' 4 L —meow- Date: 1.1 ..... _ . Required Attachments Inspector Complete:This Inspection Report is SPages long• Check comp) a forms attached: Hydraulic Performance Tank Integrity A,Soil Separation ❑Operating Permit Form iii applicable) System drawing/As•built dr wing ❑ An assessment o any local requirements that ate different from what is reCL,iee on !r••; lorrn 0 Sol Bo ng Logs 0 Abandonment form(it appropriate) ❑ Other information(list)' Upgrade Requirements(derived from Minn. Slat. § 115.55)an imminent three(lo public newel and safely(iTPHS)must oe upgraoco.re;.aces its use discontinued within ren months of receipt of this notice or within a shorter period if required by local ordinance,If the system is lading to prow:t g'o..r_ dater,the system must be upgraded,replaced,or its use discontinued within tone time required by local ordinance. II an existing system is not ra,,.r:g Al ter:v: -law, and hes al least iwo feel of design soil separation, then the system need not Sc upgraded.repaired,replaced,or its use drscondnueo nor.:,tns:s::_•:.g;-. local ordinance that is mote strict, This provision does not apply 10 systems in srorerand areas. wellhead Protection Areas,or those used,II;ounce( -: ?"..• oevorage,and lodging establishments as defined in law. wq,wwibrs4.31 Compliance Inspecrion Form for Exts:,ng SSTS a I rr1A 59/T0 39Vd ZTTEEL8?56 sT :ZT TTOZ/be/eT