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Minnesota Pollution Compliance Inspection dorm • ,• !•' Control Agency 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems (SSTS) i -- St.Paul,MN 55155-4194 11 19 311 I $ a 33 t Do 6 For Local Tracking Purposes — —' Parcel number. System status: ❑ Compliant 0 Noncompliant (based un all cuii pliance requirements) Summary Form • Property Information _ (1 — -- Property owner nante(s): `�E L T c IZ,_ -:J`h�` A DA r1�5 "Ta & ed 2_ z4 -9Y-3S Property address: _LA550 ,1pl, IZY f�`" t,,� kJ;/ e a ui A /11APIE w/1i -_-OAol Property owners address (if different): County: 44�.'t,N ._ _ Property owner phone Permitting authority: �.,t`f�t/ o F Ql�iti G Date system constructed:.IS/ 19 le Reason for inspection: !_,5 c LI`t v'et System Description 1 , - Brief system description: fl o ND S I5li/a- $ 3- 1 000coaCT Z.5(44_ I•- jn 714rjK Local permit number: Number of bedrooms: I Design flow rate: Go G ' f<Q • Is the system: In Shoreland area? 0 Yes ® No in Wellhead Protection Area? ❑ Yes ki No An U.S. Environmental Protection System serving a Minnesota Department Agency (EPA) Class V Injection Well?0 Yes LK No of Heath (MDH) licensed facility? ❑ Yes [4 No • Compliance Status(Based on slate requirements - auaiuonal local requirements may also apply.) Bas d on information gathered and reported on aft: :nea bourns, the compliance status of this system is (check one): ❑ Certificate of Compliance-valid until (3 years irorn cute of report): _ At Notice of Noncompliance-For Noncompliant systeti : • _ The reason for noncompliance is: 14/J/r5 A.;‘-':. _,€,) p i,Jfnp,i _y Er i L ) r)-% t 7U/W P T_,t:)e_i)t 1 - This noncompliant system is classified as (check one below): I Imminent threat to public health& safety 0 Failing to protect ground water 0 Not in compliance with operating permit Certification (Completed form must be submitted to the local unit of government within 15 days.) ' /hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No . determination of tuturo system performance has been nor can be made due to unknown conditions during system construction, posy use of the system, inadequ t aintenance, or future water usage. 1 �/ ' • Name: tri/ 1 t.-I )q . rte' Certification number:-rt / / L. Business license name and number: (/ l_ _'_3___ So % L j5 /! 9i3 ._-- c Name of local u overnment: (�. / G!f' 0 .(i/(-1 G / x1�_ c, Date: .2/ '7,V'7,VLC' Si:d nature: d • Required Attachments Inspcctur Complete: This Inspection Report is pages long. • Check compliance forms attached: 0 Hydraulic Penonnace Tank Integrity LgSoil Separation 0 Operating Parrnt =our: tai applicable) 14,Syslem drawing/As-built drawing 0 An esscssnientny local requirements that are different from wnat is ie:quuuu oil Ii,,:. • town &Soil Boring Logs 0 Abandonment form (if appropriate) ❑ Other information(list): Upgrade Requirements (derived from Minn. Slat. § 115.55)An imminent threat to pectic health and safety(ITPHS)must De upgraded,repriced or its use discontinued within tan months of receipt or this notice or within a snorter period it required by local ordinance.It the system is failing to protect ground .later,the system must be upgraded,replaced,or its use disconununu wrmin me time required Dy local ordinance.I1 an existing system is not tailing as oarincd,Ii law,and has at least two feel of design soil separation, then the system need not De upgraded,repaired,replaced,or its use discontinued,notwitnstanorng aril tool ordinance That is more strict. This provision does not apply to systems in shoreland areas, Wellhead Protection Areas,or those used in connection with rood, beverage.and lodging establishments as defined in law. • wq-h'wists4.31 Compliance Inspection Form for Exisriny STS