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09/23/2911 15:52 9528733112 PAGE 61105 <br /> �o� Compl ance Inspection Form <br /> Minnesota Polluti <br /> Cont�ol Agency e Treatment Systems (SSTS) <br /> 520 Lafayette Road Nofth <br /> Existing Subsurface Sewag �ns�ructions on pa�e : <br /> SS-Paul,MN 55155•A194 <br /> For Local Tracking Purposes <br /> Parccl numbet; �. <br /> System siatus: �ompliant � Noncompliant <br /> (based on a!I co pllance requi�ments) <br /> Summary Forn�+ <br /> Property Information � _. ........ ._ _.. <br /> P�operty owner name(s)� ----.•-- . .... .. ._. <br /> �. <br /> Property address: - � - <br /> Property <br /> o ner's address(it o�fferent�; Pe mitting autho�ity: �' <br /> r owner phone: <br /> Counry; `'�-� Pr Pe _--- � -.. .. .. .. <br /> pate system constructed: <br /> Reason for inspection: <br /> System Description 3 ��� ^___ .. <br /> Br�el syslem descriptlon: � �r— Design flow rete: ..., .��� . <br /> Number of b drooms l_ <br /> Local permit numher: <br /> Is the system: Yes�No <br /> �Ygg No In Wellhea Protecdon Area? � <br /> ►n Shoreland area? gystem se Ing e Mlnnesota DepaRment <br /> An U.S. Envlronmental Protection <br /> � Yes NU <br /> Agency (EPA)C�ass V Injection Well?0 Yes No of Heath ( OH}licensed facillry. <br /> COf11PI1d�Ce StdtUS (8ased on state requlrements c�a�tfof�s0 he cornP►ance status of hlspsylstem is (check one� <br /> Based on the information gathered and reported on atta __� _ _ <br /> �rtificate of Compllance-valid until(3 years from date o!report)� <br /> ❑ Notice of Noncompliance-For Noncomp►iant sYstems: _ _ <br /> 7he reason For noncomp�iance is: <br /> Fallin to protec ground water ❑ Not in compliance with ove�annq per�,�' <br /> Thls noncompl►ant syatem Is classlfled as (check one e ow : <br /> ❑ Imminent threat to public health 8 sefery ❑ 9 <br /> CertlflCatitOfl (Completed forrn must be submltted to the local unit of governmenl wlthin 15 days,) <br /> I hereby y �nfo��as been nor enCbermed dduer o/unknown conrd fionsf dv�ngtsysternscor�sir�������' <br /> certif that all the necessery � <br /> determination of future sys�em performance <br /> possible abuse of fhe sysfem, inadequ te maintanance, or future wa� �C�ficatlon numbsr' ���_-`-._-�-�� <br /> Name: _, ^� - Q�--- -.._. _... . or <br /> Business license name and number: � <br /> --- <br /> Name oi Iocal unit of g ment �- <br /> Date: � 1�........ ..._... .. .... <br /> Signature; <br /> Required Atta hments <br /> Inspecto�Co plete;This Inspection Report is pages long. <br /> Check comp ' nee forms attaehed: �ydraullc Pertomna���Ta k Inleg�ily �Soil Separ2tlon ❑ODeraling Perm�t F�rm i�l <br /> apvlirabie) System drawing�Da dontm nvll(ortnp pro0eate)eO d�n r inlormaQOn(��t);��hat are diflerent from wnat�5��Q������^ �r�`- <br /> lo� ❑ S il 8o g l.o9g ❑A --- ---. <br /> U pgrade Requ�i�eme��(da�a��a eiD o/A S o��e o'wf Ain a,shorle�p� od'I requ�ed�'y locs!ob na�ceell lrne syslemusl/a li p Ao p n��rey%�yec .; <br /> rrs use Or'scont <br /> �ate�,rne sys�em musl D�upp►adsd,r'ep�ace0,orifs use diSConNnued wllhln Ihe U mQB���C�a��rre)O�aCBd,l o�ils use d�conf nue0^naiw���s'��s' c? �p.• <br /> low, and l�es af�eesl fwo(eeJ o!dsslpn so�7 sepe�a��a�.tAs pf�Y Sys�m need�o�o vpg P <br /> local oi0ina�ee I�al is more Slnef. TAiS Orovia�0�tloes l70�e lo� sloms r'n sho�e and a�r.es, We1lnead Prolecfion Arees,o�l�ose uscd��i:�����P�"�� "'" '=== <br /> eeverege,end lodglnp esladl/shmonts aa deRned in 1+w. <br /> ., .��---- �,�....�.:.... c�...� Fr,r F��c•inc CGT� <br />