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��>� ; ��,�,r�� - , ��e�g ��s�s��a��^ ��r�g� ��e��ea�� s�ems ��3 Instructions on pa�e 7 Parcel number: For Local Tracking Purposes: System status: [�Compliant ❑ f�oncompliani I (based on all combliance r2quiremenfs) � ��i�i�1�� OPa� �roperty �n�orr�a�io6� Property o�roner name(s): Property address: � �� C...p er �v �-�, • t t,r�/�r � Property o�roner's address(if different): Counb�: iv, Property o��mer phone: Permitting authority: , � /�,► Date system constructed: �� Reason for inspection: f�Q,,l� S�S�E.'6'� �E'SCB"l��Ofl Brief system descriptq�-��fl�� ✓ICS -- �D V w�� f y S 7`C ��... Local permit number: /V�� „ iVumber of bedrooms: Design flo�v rate: Is the system: In Shoreland area? ❑Yes �Ci�lo In tNellhead Protection Area? ❑Yes �No An U.S. Environmental Protection System serving a t��linnesota Depariment r�gency(EPA)Ciass V(njection WeII?�Yes �No of Heath(MDH)licensed facility? ❑Yes [�No �OiTi�11�RC2 J'C��19� (Based on state requirements—additionaf local requirements may afso apply.) Based on the information g�thered and reported on attached forms,the compliance status of this system is(check one): �Certificate of Compiiance—vaiid until(3 years from date of�eport): ❑ Notice of Noncompliance-For Noncompliant systems: The reason r"or noncompliance is: d 3�is norc�rnalian:sys�e�is classi��eci as(c��c{c�n� beicvv): ❑ Irnminent threat to public health&safety ❑Failing tn protect ground�n.�ater ❑ Not in compliance v�ith operatrng permit Ce3"�i71Cd�iO�l (Completed fonn must be submitted to the local unit of government�P�ithin 15 days.) I herehy certify ihat all the necessary informatron has been gathered to determine the compliance status of this system. No determrnation of future sysfem performance has been nor can be made due to unkno�vn conditions during system construction. possible ab e oi the system. inade at malntenance, or ruture!-��ater usage. Name: /1 ,��(,J � /�,�EU Certification n�nr�ber: l �,� Business license name and number. ,tp (.�iC S � �k/S . �� or Name or local unit of vemment: � � � g Signature: O .r-- Date: // D `� _ �ei��1�"ed ,�$t�C��9��5 fnspector Complete: 3his inspection Report is�pag�s fong. Ciieck comp99ane2 fiorms at4ached: �draulic Performance ❑Tank Integrity Soil Separation ❑Operating Permit Form(if applicable) ❑System dra�r�ing/As-built dra�nring ❑An assessment of any focaf requirements thai are different from what is required on this form ❑Soil Boring Logs ❑Abandonment form(if appropriate) ❑Other information Qist): Upg f2d@ R8p!!lPe�17011ts (derived from ft9inn. Stat.§915.55)M immin=n!thraai'ro public heaRn ar,d saety(I rPHS)must be upgrGed,replaced or its use drsccntinued avrthm ten mentns oi receipt ci thrs r,otice or wrfhin a shc�e.r peria7 ii rcquirc-d by Icca/az7rnance /f th,e system is failing to pretect g�ouno water.the system must 6e upgraG�',repfac�:,or iis use d�scontinued wifnin the�ime reouir�by la:al ordinance.!f an existing system rs not fading as dennetl in law.and has at least hvo fest or d srgn�cil s2p2raiion.then tt�e system need not 1�e upgradzd,reparred,iealacecl,cr rrs use discontinusd,notwithstai7ding any Ic�al ordinance ihat is mor2 strici Ti�is provrsicn Coes nci apply b syste�ns in c�r�,-alartd araas. liiiellhead Proiecfron Areas.or tt�ose used in connection�a�ith reod. Deve2ge,and IeJging establishments as d=fined in/a�a� wG-wwists�F-3 i Comotrance Ir,spectien Form for Existing SSTS 41?/08