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<br /> 04/26/2610 07: 28 9528733112 PAGE 01/05 v
<br /> MinnesotaPollution Compliance Inspe�tion Form
<br /> Control Agency
<br /> SZolafayeaeRoadNorth Existing SubsurFace Sewage Treatment Systems (SSTS)
<br /> S�.PauI,MN55155�4194 InSLruCtions on pa�e '
<br /> Parcel number; For Local Tracking Purposes
<br /> System status: �Cempliant ❑ Noncompllant
<br /> (based on ell coMpiiance requ/rements)
<br /> Summary Fvrm
<br /> Property Information
<br /> Property owner name(s): ! �!� ���U �� „__,_.__._... ,.
<br /> Property address; Y � • ' - � I? �' __......... ,
<br /> Property owner's address (i1 different): _,__,_.,___..._,. _
<br /> County; � Pr�perty owner phone; /��- yf�� � �y�Pe�mitting authorlty: , ._ , , , _
<br /> � 1,,
<br /> Oate system constructed: . G O Resson for inspection: �Q c�-- �_.,,, ,. , . _
<br /> r r
<br /> System Descriptian
<br /> Brief system descriptfon: � �G�� ��� �- S "'� f12�`' � y�'� __.,,,, ,. .
<br /> Lo�al permit number: Number of bedrooms: Design flow rate: _. �Q.�:�
<br /> Is the system:
<br /> In Shoreland area? ❑ Yes �,No In Wellhead Protectlon Area? ❑ Yes �No
<br /> An U S. Environmental Protection � System serving a Minnesota Department
<br /> Agency (EPA) Class V Injection Well?� Yes �.No of Heath (MDH)licensed facility? ❑ Yes �] No
<br /> COI11p�1��C@ StdtUS(Based on state requirements-addllional local requirements may also apply,)
<br /> Based on the inFormation gathered and reported on attach�d forms, the compllance status o(this system is(check one�
<br /> �Certificate of Compliance-valid untif (3 years from dafe ol reporl): _________,.
<br /> � Notice of Noncompliance- For Noncompliant systems:
<br /> The reason for noncompliance is:
<br /> Thls noncompHant syatem Is classiffed as (check one below);
<br /> ❑ imminent threat to publlc health 8 safety ❑ Failing to prolect ground water ❑ Not in compliance wi�n opera��nG p�rT;:
<br /> C2�t1'f1Ca�iOf1 (Completed form must be submitted to the local unit of government within 15 days.)
<br /> f hereby certify thal a►1 fhe necessary infoimation has been gafhered lo determ�ne fhe compliance ste�us o!Ih�s sysre��� r�c
<br /> determination of luture sy5tem pe�formence has been nor can be mede due to unknown conditions during system consu��_t����
<br /> possible abuse ot the system, �nedequ te main�nance, or furure wsfer usage.
<br /> Name: _.,,��� ���IL�� Certification number, ��y�-.\._ .... .
<br /> 8us�ness license name and number: ��y�,�Ea�L111[� �,,��1(Q5�`�C_ r�j, 'rJ—��—_.._._. or
<br /> Name of Iocal unll o ernment: „___ . ... . .
<br /> Signature; ` - v Date� /��... _ .._.__ _. _
<br /> _ �
<br /> Required Att�ch�ments Inspector Completg; This Inspectlon Report is �j pages long.
<br /> Check Compfla ce forma attached: �Hydraulic Perform9nce ,CJ�Tank Integrlry �5oil Separa�ion ❑ Operaling Perm�� F�rm��'
<br /> applicab�e) ��yslem drawing/As•built drawing � An assessment of any lacal requirements thet are GiFferent from wnai�s reo��rce on ;r.�s
<br /> form ❑ Soil 8oring Logs ❑AbanOonment forrn (�f approprlata) ❑ Other information(li�t);
<br /> Upgrade RBqUifBmefltS (deflYBd/rom Minn, StAt.§ 115.55)An lmminenl threal lo puDlic fleallAanO srlefy(ITPHS)musl De upgrsar,o.reorA�ec :
<br /> rfs use disconli�ued wilAi�lsn monlha ol ieeelpf of Ihla noUce or wiiAin a ahoRer penod�l�oQuirod Dy Ipcef o�d/nenee,I(tne sys(em�s Jadmg ro pro�eci�ro�r.c
<br /> Nalo�.Ihe system musl D�up�radsd,ropl�ced,orita use discanUr+ued wilhin IHc lin+e�e0v/rod Dy ioea!orvinance. I!en exlsfing sys�em�s noi lac.r•g as:ar:�a: -
<br /> �a..,enC nea ar�eaar rwo/��f old��ipn aoil separo�;on,inen IAe eystem ncee nol ee vpgreoeo,�epelred,repleced,or ils use a�sconbn„ed.no�•�.u+r>:�.:.::;:-•
<br /> rocal ordinancs fha!�s�+'�oro sfiicl. Th;s provlslon does no/apply lo sysfems in shoreland areas, Weflhead Piofeclion Areas.or Mose useo���;o���ec:.;�: .� - _._
<br /> oe�erage. a�d 1odq�np eslaDlisnmenrs as tlellned in law.
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