705 Old Long Lake Road - Septic Compliance

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N TRSDTA POLLUTION CONTRO L OL AGENCY Compliance inspection report form 520 Lafayette Road North Existing Subsurface Sewage Treatment System (SSTS) St. Paul, MN 55155-4194 Doc Type: Compliance and Enforcement Instructions: Inspector must submit completed form to Local Governmental Unit (LGU) and system owner within 15 days of final determination of compliance or noncompliance. Instructions for filling out this form are located on the Minnesota Pollution Control Agency (MPCA) webslte aP t ca.s ate mn,us!sites/default/fileslwc-wwists4 31a,gdf. Property Information Local trackin number: Parcel ID# or Sec/TwplRange: Reason for inspection Local regulatory authority info: Property address: - Ownerlrepresentalive:. A NA5_Vp V 0 J) �4 Owner's phone: Brief system description: '&-jriva I•01.40y-(1t1 i1000y.1 ftJwa4.(4fA%4_ ty�t MvsfsAZ� 5'�yiv� u��^i43 4 %tdt"F a0V t 'A* 'Y.r 190)S V)A Womo System status System status on date (mmlddlyyyy): 5�r,_a- 2 Compliant -Certificate of compliance- (Valid for 3 years from report date unless evidence of an imminenf threat to public health or safety requiring removal and abatement undersection 145A.04, subdivision 8 is discovered or a shorter time frame exists in Local Ordinance.) ❑ Noncompliant- Notice of noncompllance Systems failing to protect ground water must be upgraded, replaced, or use discontinued within the time required by local ordinance. An imminent threat to public health and safety (ITPNS) must be 'Note; Compliance Indicates conformance with Minn. upgraded, replaced, or its use discontinued within ten months ofreceipi R. 7080.1500 as of system status date above and does not of this notice or within a shorter period if required by local ordinance or guarantee future performance. under section 145A.04 subdivision 8. Reason(s) for noncompliance (check all applicable) ❑ Impact on public health (Compliance component #1) -- Imminent threat to public health and safety 0 Tank Integrity (Compliance component #2) - Failing to protect groundwater ❑ Other Compliance Conditions (Compliance component #3) - imminent threat to public health and safety ❑ Other Compliance Conditions (Compliance component #3) - Failing to protect groundwater ❑ System not abandoned according to Minn. R. 7080.2500 (Compliance component #3) -Failing to protect groundwater ❑ Soil separation (Compliance component #5) - Failing to protect groundwater, ❑ Operating permit/monitoring plan requirements (Compliance component #4) - Noncompliant - local ordinance applies Comments or recommendations Certification i hereby certify that all the necessary information has been gathered to determine the compliance status of this system, No determination of future system Performance has been nor can be made due to unknown conditions during systam construction, possible abuse of the system, inadequate maintenance, or future water usage. By typing my name below, I certify the above statements to be two and cormcf, to the best ofmyknowledga, and that this information can be used for the purpose of processing this form, Business name: 41 '( I L' Certification number:-� Inspector signature: t License number: O 1ys document has been electronically signed) Phone;��gey�, Necessary or locally required supporting documentation (must be attached) [2 Soil observation logs Q System/As-Built ❑ Locally required forms Q Tank Integrity Assessment ❑ Operating Permit Q Other information (list): Sj�� it Go-vei¢ https://www.pca.state.mn.us 651-296.6300 800-657-3864 Use your preferred relay service Available In alternative formats wq-ww1sts4-31b • 4/2812021 PQge 1014