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IWlinnesota Pollution Compliance i�nspection �orm
<br /> C�ontrol A�ge�tcy �xisting 3ubsurFace 3ewage Treatment �ys#ems (SSTS
<br /> 52p I.afaye�z�Road North �
<br /> 54 Paui,MM 55155-4194 Doc Typ�.•Complience and Enforcemenf
<br /> Instructions on pag�6
<br /> Summa�y Farm (Completed form musi be submitted to tho local unit of government within 15 days,)
<br /> Parcel number:
<br /> System status: ❑Compliant � Noncompliant y For Local Tracking I�urpoges:
<br /> (based on all compliance requlrernents)
<br /> Propet-�y Info�mation " -�� -�`
<br /> Properly owner name(s)� JG�1�.,� '�&(��,l.,�j�j Property owner phone: ��Z��?,qr
<br /> Propeety address: �f� p '�,4U I��,,Y�j.S►�_ ._ � Q��p
<br /> Property owner address(if difFerenc): __w�, " -- "
<br /> County:��',��'e�,� Permitting authority; G _0� p'�Q�,,y,�� �
<br /> Data�system canstructod: � °► 9 Gl ;G ��„ Reaso�for inspection: ��\I�p�f,1,^�����`
<br /> System Descr�p�t�on
<br /> I�rief system doscriptlon; 10 0[� o,.� �' 7 S� � '� -�L �y�1�y, 'I
<br /> �--..,...�- �°'��,. / S �' I17 `C IG� �1.��1.1J�.s`� P1��"I�OL1�.f�F
<br /> Locel permit numb'er __ „ Number of bedrooms: �, Design flow rrate: ��-� ,_
<br /> Is the system: '
<br /> In Shareland area7 �Yes � No In Wellhead Protection Area? ❑Yes �No
<br /> An U_S_ Environmental Protection System serving a Minnesota Department '
<br /> Agency(EPA)Class V Injection Well�0 Yes � No �f Heath(MDH) license�d�faciiity? ❑Yes �No
<br /> COt17pIia�lCe Std�Us (13ased on state requirements-�dditional local r�quirements may alse apply.)
<br /> Based on the informa�lon gathe�� and reported on attached forms,the compliance status oTthls system is(check ono):
<br /> [] Certificate of Compliance-valid until (3 years from d.ate of report):
<br /> � Notice of Noncompliance-Fo�Noncompliant systems:
<br /> The reason for noncompl�an�ce Is: �r� -�'W��yS �� 5����Q�
<br /> Yhls noncompliant syst��rn la classifled a�(chock one below): ^ y �
<br /> ❑ Imminent threat to public health 8 safety �Failing to protect ground water ❑ Not in compli�nce with oper2ting permit
<br /> Cert9f9cation
<br /> 1 horiaby certify thaf all the necess,ary information has been gath�red tv determfne the compliance shatus oifhis systom.No
<br /> dete►mination of future systam perfarmance has been nor can hs;mad�dve to unknown condfSons during system construcflon,
<br /> possible abuse of the system, inadequafe mainl�enance, or futr�ro water usage.
<br /> Narne: $i�11�9, .{j. 5�1�6�l Fi'�S _ Cortiflcallon�number: ��
<br /> Buslness Ilcense name and numbsr. 5-'P � �.r��N� 1�1 C , L1�Le����� p��` �(�,'3-y`)�-_3Sbb or
<br /> Name vf Iocal unit of government:
<br /> Signature: .� V� �'��-�`-"�—�-- __,.... __.��.,.. Date: .,._�y.•,�:.5�a 0 ,_�
<br /> Required Atxachment�
<br /> �Hydraulic PerFoRnance ❑Tank Integrity [� Operating Permit Form (if applicable)
<br /> Soil Baring Logs, (�5oil Separation
<br /> �'System drawing/As-built drawing ❑Any local requirements that a�e different from what is required on this fiorm
<br /> � Other information (list)�
<br /> Upg�de Requlreme�tis (derivgd from Minn, St�t.� 115.55)An Imminent th►gsP to publlc heetth and safely pTPHSJ musrbe upgreded,
<br /> .2placed, or its use discontlrn�ed wifhin tgn mortths of reCeipt of fhis notice or wlthln a ahol Mr period if rr�qulred Gy loca/ordin�n�e.!f tho system/s
<br /> failing fo prof�ec�ground wAter,the systom must bo upgnded,raplace�l�r its use di�contlnued wlthln fhe time iequired by Iccal ord/narlce, l�nn
<br /> existing syslem IS not failing as defned li�law,and has at leasC Rwo feet of design soil separat/on,then 1he system need not b�upgraded,iepaired,
<br /> ►eplaCed,or its usc d/sconflnupd, notwithstanding any local ordinancc�that/s more stricf, This provision doos not apply fo sy,3tems in shoreldnd
<br /> areas, WeNhead PrDtection Areas,or thoso ifsod!n connecdon WRh food, beverege,and/odgln,q esfablishments es defined in law.
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