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. 11116,!2011 02: 31 ?634975011 SPTESTINGINC PAGE 03109
<br /> Minnesc�ta Polluti�on Connplian�e Inspectaon F'�rm
<br /> �`„ Contr4l Ager�cy
<br /> �xOst�ng Su�surtace Sewage Treatttaent 3ystems (SSTS)
<br /> 52Q Laf�yere Road North
<br /> 5L Paul,MN 55155-4194 Dr�c Type:Complience and Enforcoment
<br /> InstrUCtions on page 6
<br /> Sumnrwary �o��A1 (Completed form must be submitted to the local unit of government withfn 15 days.)
<br /> Parcel number;
<br /> System status: �I Compliant [7 Noncompliant � �or Local Tracking Purposea: ��—"`—'
<br /> (based on all complianco requrrements)
<br /> Property Infiarmation
<br /> Property owner name(s): D� .µ��j��y,li�g���.,n� Property owner phvne: l��Z r� Ip��IA�^�
<br /> Properiy address: �t�q 5 ,�ou SJ��, l.l�-_ O'LD 5J-C�
<br /> Property owner address(if differenq: "�"`"—"
<br /> County:,__ ��1.�1���,..), Pormitting autHority: L�_p�_ pQp�p
<br /> Date syst,em constructed: �9�� ,__ Reason for lnspectian: ���^'
<br /> �����.+s�,.
<br /> System DQscript�on �
<br /> Brief system descrlption: a ^1300 ga1�54•R-�4�,1. �1g1�,�S op ��w���y����K�au�o lu �et�5�����,1
<br /> looal permit number: ___ Number of bedrooma: (p Design iiow rete: �pp
<br /> Is the system: "
<br /> In Shoreland area? �Yes �Nv In Wellhead Protection Area? 0 Yes � Na
<br /> An U.S. Envlronmental Protecfion System serving a Minnesota Dapartment
<br /> Agency(EPA)Class V Injedion Well?❑Yes '��Jp of Neath(MDH) lic2nsed facility? ❑Yes � No
<br /> COfT1p�1d11C2 StdtUS (Based on state 2qr�iroments-addif.i�rial local requirements may a/so apply.)
<br /> Based on the infom�ation gathered and reported on attached forms,the compliance status of this system is(check one):
<br /> �'Certificate of Compliance-valid until(3 years fium date of rgport):
<br /> ❑ Notir.e of Noncompliance-For f�oncompliant systema: '
<br /> The�eason for noncompliance is:
<br /> This noncomp�liant syatem is classified as(check c�ne Rzefow): ^ � � '—
<br /> [] Imminent tliroat to publle health 8 safety ❑ Failing to protect ground water ❑ Not ih compllance with operating permit
<br /> Certyfication
<br /> I hereby cerfr(y that all thB necessery lnfa►mafion has been ga�h�red fn detennine the compllsncQ stafus of thls system. No
<br /> de(�rmination of fulur�system perfnnnance has been nor can b�mede due to unknown conditions during sysf�m cronsfruction,
<br /> possible abuse of the syst�m,inadequate maintenance, or f�ture weter usage.
<br /> Name: �.'v''�1��,.1 .�j�,5G�)���1�i�S Certification number. �'L_�
<br /> Buslness Ilce�s�e name and number: S-� -��i�j U1,L•�,4�,��L,��i�.,������_y��_ 3 ti,,eo�o or
<br /> Name af local un t of government:
<br /> Slgnatur�: �%(ti,.��� ,w_._ ^ _._ _ �
<br /> ..�_.,. Date: ���-2101�}...—
<br /> Required Atfiachments
<br /> � Hydt'aulic Performanr,� � Tank Integrity ❑ Op�rating Permit Fotm (if applicable)
<br /> � Soil Boring Logs � 5ofl Sepsration
<br /> � System drawing/As-built drawing �Any local requirements fihat are difFerent from what ls required on this form
<br /> ❑Other information (Ilst):_ __ _ W
<br /> Upgrada Requirements(der;ved fro►h Minn, Sfat.§ 1 i5.55J An lmminent threa!M publlc healtl�and seRety(ITPHS)must be upgraded,
<br /> .replaced, orlts i�aP discolt6nucd w/Nrin f�n monihs of receipt of tltls no�ice dr withln a shorf�r peliod if rtaqulred 6y Ir�cel oidinance.lf the system i3
<br /> falling to proleCt ground ivftfer, fh�.�8y8tem must be upgradod,replAped,or its use dlscontinued wlthln tlie llme rQqui►�d by local ord/ne►1cE. lP en
<br /> existing system fs not fai!!ng as dE�fTned fn law, ane nas at loast two feet of d�sign soll separation, than the syster»need not bo upgraded,repaired,
<br /> rt�pl9ced, or its use discontinued,notwtthsFending eny locaf oMinc�nce that!s mo�e stNct. Thls prvvi8ion does not apply to systems in shore%nd
<br /> areas, Wellhead Protectlon Arr.as,or those used in connectlan wfth food,6ovarape,and lodging es�abflshments as defrned!n law,
<br /> www.pca.state.mn.us � 651-296-6300 • 800-657-3864 • TTY 651-z82•5332 or B00•657•3864 • Available in altemztive formats
<br /> ��i.w_.��..:../.�I ]1 . J11/IAH
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