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Minnesota Pollution <br />Control Agency <br />520 Lafayette Road North <br />St, Paul, MN 55155-4194 <br />Compliance Inspection Form <br />Existing Subsurface Sewage Treatment Systems (SSTS) <br />a,1� . <br />Parcel number: <br />System status: <br />(based on all corm <br />Summary Fc <br />Property Infc <br />Property owner <br />Property addres <br />Property owner' w .... %„ ,,,, ,, ,,,,, <br />Instructions on page <br />County: 11-Mittli P party owner phone: `��.�``lt%j-7S)`i permitting authorlty: C j <br />Date system conns� Reason for Inspection; <br />System Description <br />Brief system description: <br />Local permit number: <br />IN <br />Design flow rate _6700 <br />Is the system: f <br />In Shoreland area? ❑ Yes KNo In Wellhead Protection Area? ❑ Yes %� No <br />An U.S. Environmental Protection System serving a Minnesota Department " �f <br />Agency (EPA) Class V Injection Well? ❑ Yes KNo of Heath (MOH) licensed facility? 0 Yes X No <br />Compliance StatUS (Based on state requirements —additional local requirements may also apply.) <br />Based on the information gathered and reported on attached forms, the compliance status of this system is (cneck once <br />KCertificate of Compliance — valid until (3 years from date of report): <br />❑ Notice of Noncompliance - For Noncompliant systems: <br />The reason for noncompliance is: <br />This noncompliant system Is classified as (check one below): <br />Q Imminent threat to public health & safety ❑ Failing to proteot groundwater ❑ Not in compliance wilh operating perm,,. <br />Certification (Completed form must be submitted to the local unit of government within 15 days.) <br />i hereby certify that all the necessary information has been gathered to determine the compliance status of this system; r, <br />determination of future system performance has been nor can be made due to unknown conditions during system consvoci. �10 <br />possible abuse of the system Inedequ to maintenance, or future water usage. <br />Name: _. CL ,y Ltror- k� MA Certtficatton number: 6R <br />Business license name and number: j,-A %cj Sgysfi" 5. or <br />Name of local <br />Signature: <br />Required <br />Inspector Complete: This Inspection Report is 5�_ pages long. <br />Check complf forms attached: i�lydrauUc Performance 04ank integrity (Ksao Separation p Operating Permit Form w <br />applicable) tarn drawing/As-built dra ng ❑ An assessment of any local requirements that are different from what .9 reou,reo on iris <br />torn © S Boring Logs M Abandonment form (it appropriate) 0 Other Information (fist): <br />Upgra a Requirements (derived ft m Minh, Slat. §415.55) An intminenf threat io public health and sarary (17P)1S) rrwsi be upgraceo. renaa: ac : <br />Ifs use d/s00r111nl/ed wfwn ten months of reCalpt or iNS nowke of within a stlonar period irrequired by Idca1 ordinance. if the system 4s taibng to protect <br />water. IN syslom must Se uppreded, replaced, or Its it" diseonfinued within the firne required by)oeat ordinance. It sit existing sys,em is not tan,i:s as re;'�r: <br />law, and ties al laaSI two feet or design sod separaboe, than the system head not be upgndad, rapaimd, replaced, Wits use discont,nueo. nor,�,;ns•. s: -:; s�. <br />tocar ordinance inat+s mom stn'ct. This provision does not appry 10 systams in Shoreland areas, Wallhead PlateCt on Areas, or rnose useo m ;once <br />boverege. and todginp establishments as dented in law, <br />wq•wwisrs4.31 Compliance Inspection Form for E+i5:rng SSTS <br />411108 <br />SO/TO 39a8 ZTTEELSZ96 6Z:b1 TTOZ/90/90 <br />