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• Minnesota Pollution Compliance Inspection Form Control Agency Existing Subsurface Sewage Treatment Systems(SSTS) � 520 Lafayette Road North 5t.Paul,MN 55155-4194 Doc Type:Compliance end Enforcement Instructions on page 6 • Summary Form (Completed form must be submitted to the local unit of government within 15 days.) Parcel number: System status: ❑Compliant ❑Noncompliant For Local Tracking Purposes: (based on all compliance requirements) Property information Property owner name(s): eit t vt s" H U Sl"' Property owner phone: 4,aos9- Property address: 4,VO SO, Ot-^sz, G4•Ysbt n. 'SAS 'Po. C74.0)-10 • Property owner address(if different): • County: 1444 RN%.A Permitting authority: (...y411 pc- o ).tO Date system constructed: 5"`d-9Ti Reason for inspection: Prd4 G'( "kr-44-146' System Description Brief system description: a-)000 er i SelT41 i01111-r tooday.,I VII ko,17 4 S 1 4'1.10.111%, i 1o ><5II't2OL1L8op Local permit number. Number of bedrooms: Li Design flow rate: L000 is the system: In Shoreland area? 0 Yes •No In Wellhead Protection Area? 0 Yes ®No An U.S.Environmental Protection System serving a Minnesota Department Agency(EPA)Class V Injection Well?0 Yes ®No of Heath(MOH)licensed facility? ❑Yes 19]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): 0 Notice of Noncompliance-For Noncompliant systems: The reason for noncompliance Is: This noncompliant system is classified as(check one below): 0 imminent threat to public health&safety 0 Failing to protect ground water 0 Not in compliance with operating permit ' Certification I hereby certify that all the necessary information has been gathered to determine the compliance status of this system.No determination of Mum system performance has been nor can be made due to unknown conditions during system construction, possible abuse of the system,Inadequate maintenance,or future water usage. Name: 5/1.-OVA Certification number. (0 2,1 Business license name and number. 5 Q 4.6fr. 1' 11J C, 1 1 Q u-;qti pu*'7 to3-4' q-SSW,or Name of local unit of government. Signature: - y--- Date: ii-i4S-oZo)O Required Attachments Hydraulic Performance ®Tank Integrity 0 Operating Permit Form(If applicable) ®Soil Boring Logs ®Soil Separation ®System drawing/As-built drawing 0 Any local requirements that are different from what is required on this form ❑Other information(list): Upgrade Requirements(derived from Minn.Stat.§115.55)An Imminent threat to public health and safety(ITPHS)must be upgraded, 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 failing to protect ground water,the system must be upgraded,replaced,or its use discontinued within the time required by local ordinance.If an existing system is not failing as defined in law,and has at least Iwo feet of design soil separation,then the system need not be upgraded,repaired, replaced,or its use discontinued,notwithstanding any local ordinance that is more strict.This provision does not apply to systems in shoreland areas,Wellhead Protection Areas,or those used In connection with food,beverage,and lodging establishments as defined In law. www.pca.state.mn.us • 651.296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative fonnats wq-wwists4-31 • 4/24/09 Parr 1 of it