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07/21/2008 10:53 9528733112 PAGE 01/05 t � �� MinnesotaPollution r Comp iance Inspe�tion Form Control Agency �� SZOLafayetteRoadNorth Existing Subsurfac Sewage Treatment Systems (SSTS) 5!.Paul,MN 55155•4194 Instruc�ions on page � ParCel number For Local Tracking Purposes System status: �Compliant ❑ Noncompliant (based on a/l complisnce requirements) Summary Fvrm Property Informatian , . Property owner name�s): , __ _ � . . _ _ _ Property address: ��V� �✓ ► ^ ��0�0 ----... ...__.. __... Property owner's address (if differenq; ___ _ ___ Counry; � Property owner phone: Permitting authvrity: e,� Date s stsm construcSed: _\ Reason for ins ection: �^ i Y / ...__... .. System Description Brief systern descriptlon: �. �� S Local permit number; Numberaf bedrooms� Design flow rate: __ �j�� Is the system; In Shoreland area? ❑ Yes �,No In WeNhsad rotectlon Area? D Yes �YNo An U.S. Environmental Protectfon Syslem servi g a Minnesota �epartmenl Agen�y(EPA) Class V Injection Well?❑ Yes �lo of Heath(M N)licensed facility? ❑ Yes �o COR1PI1df10E StatllS(Based on state r�quirements—addltional local re ulrements may also apply.) Based on the informatfon gathered and reported on attached forms,tMe co pliance status of this system is (check one� �Certificate of Compllance—valld untll (3 years from dale ol r2portJ: ,� W__.______. _ Q Notice of Noncompliance• For Noncompliant systems: 7he reason for noncompNance Is: ._.___.... _,,_. This noncompliant system Is clasaiffed as (check one below): ❑ Imminent threat to public health & safery �] Failing to protecl gr und watvr ❑ Not in compliance with oper��ny perrr�,; C2rtif1Cet10fl (Completed form must be submitted to the local unit of go ernmenl within 15 days.f I hereby cert;ly �hat af1 the necessery information has been gathered to de rmine fhe complience status of th�s sysler�, r�c � defermina�ion ol futura sysiem performance has bean noresn be made d rv unknown condifions dunng syslern ca�s�r��c;��•�, possr'b/e abuse o/the system,inadequ te meinlenance, or luture water us ge. Name: __��,� ��(�,� Ge Ificatlonnumber; 1��.___.. Business license narne and number: ��Ln� S��j„ Q�_„__._„ _ or Name of local unit of overnmenC — --- -- Signalure: Date: _0.. _ ...---.. .. .. Required Attachments Inspector Complet :This Inspection Report is � pages long. Check campfi ee forms attached: �Hydraullc Performance �Tank Int grity �Sal Separatlon ❑ Operaling Perm�i �o•m i,' apO�iCaple) �System drawinglAs-Guilt drawing ❑An a5Se95men of any loca requiremenLs that are different from whal�s requ�rE�c on :r�s form ❑ So�l 8oring Logs 0 Abandonment form(If approprlate) ❑ Otner info alion(li�st): Upgrade Requirementa (derived Irom Mrnn. Stat. §115,55)An imminenl tnre I�o puDflc heelth and aalefy(ITPHSJ m�sr�e upg�aoeo.:�o�acea � �ts use discontlnued wlfhln Isn mo/1Nt dreteipf o/IAia nof�e o�wl�hln a s�o�et penod il re uired Cy loca!ordlnrrlCe.If l�e syslem�s la,hng ro e�ole:r,��,.r_ waler, Ine sy�tem mus�w uppisdl0,��pfats0,o�iis use diaconflnued w�f/+in l�v lime�equi d by loee!o�dlnanee, ll�n o�%sling sysiem�s noi!.�,:.�;;vs ce�-a: - law.and has af 1e•aa�lwo leel of dea/pn solr seps�sl�on, ►l��n Ihe system nee0nol De upg/a ,rapeired,rop/eceC,ol rls ude discontin�ed.nonv,;ra�a:;;::y;-, rocai ordinance ihai�s more svlel. Thr's provislon does nof app7y lo sys�ems in s�orNdnd ar as, Wellheao Protec(Jon areAs.o/1�ose used�r:onr.z��.;;:,.:• •,:: oeverege,and lodging rslebflshmenfs as Oe�neO rn law, �