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<br /> � ����� �}���5��� �'�i������ � �� Compliance Inspection Form
<br /> '���, .� �or►�ra)Agen��r
<br /> ���,��Q�,����, Existing Subsurface Sewage Treatment Systems (SSTS)
<br /> 5t Paut,Rrt1u s51ss-a19�ct Iristructions on page 7
<br /> Parcel number. For Local Tracidng Purposes:
<br /> Sys6em status: ❑Compliant ❑Noncompliant
<br /> (based on a!!compliance requirements)
<br /> Summary Form
<br /> Property Information
<br /> , Property owner name(s):
<br /> Property address: "j���� '- ��/Z� C c4` /t G...�c7 c�r i2 ,
<br /> Properly owne►'s address(rF different)_
<br /> Courrty:�c:��vfi�i✓ Property owner phone: Permitting authority: � . �a, c9� ���G��Q
<br /> —�
<br /> Date system constructed: Reason for inspection: ����
<br /> System Descripfion
<br /> Brief system description:f►j G J,�;��'�S�t�,� �'� �R K,�'�� / -� f� l�� /�v��/�iv��
<br /> Local permit number: �r (}� �, Number of bedrooms: �.� Design ftow rate: "Z��7
<br /> Is the system:
<br /> In Shoreland arsa? ❑Yes [�No In Wellhead Protection Area? ❑Yes �No
<br /> An U.S. Environmentai Profiection System serving a Minnesoia Department
<br /> Agency(EPA)Class V Injection Well?�Yes �No of Heath(MDH)licensed facility? ❑Yes �No
<br /> C0117P�1dhC2 $tdtUS (Based on state requirements-additional local requirements may also apply.)
<br /> Based on the information gathered and reporfied on attached forms,the compliance status of this systiam is(check one):
<br /> �Cerlificate of Compliance-valid until(3 years fiam date of report):
<br /> ❑Notice of Noncompliance-For Noncompliantsystems:
<br /> The reason fo�noncompliance is:
<br /> This noncompliant system is classifled as(check one belowj:
<br /> ❑Imminent threat fio public health&safiety ❑Failing tio protect ground water ❑Not in compliance with operating permit
<br /> C@I"t1f1Cdt101'1(Completsd form must be submitted to the local unit of govemment within 15 days.)
<br /> 1 hereby certify Ehat a!1 the necessary information has been gathered fo detem►ine the compliance status of this system.No
<br /> determination of future system performance has been nor can be made due to unknown conditions during system constniction,
<br /> possib/e abuse ofthe system,inadequate maintenance,orfuture waterussge.
<br /> Name: �t7/1 C/1/ � �j ���,;��v Cer6fication number. �3' �
<br /> Business license name and number. �g j'��.-v �C1�S f `�!L s/J, cJ £iz.ay�t�,� �1/ or
<br /> Name of lopl unit of govemment ; �� /���i/�%
<br /> ....-.�
<br /> Signature: •' G�,,� Date: � � /zi
<br /> Required Attachments Inspector Complete:This Inspection Report is�pages long.
<br /> Check compliance forms attached: �(Hydraulic Performance �Tank Integrity �j Soil Separation ❑pperating Permit Form(if
<br /> appficaUle) ❑System drawino/fis-buift drawina ❑An assessmenf oi any focal requirements thaT are different from�nihaf is required on ihis
<br /> i)''Itl i� ,il� i�l"i�l(� ...%,rc I i i".I?,-1'.'�)fi L,it i� - .�i�il �-,�.,��t;:'.el _ �'�G.I�.-� '-,�I�.�.i ��,..,�:
<br /> ._— — ..i] . _.— . _ '. . __—..�.,n:,7� ,�.c.,�. �l.d�. .�'�il �.L ...8�i �� ; �bi L.T��r�..�ti� . -_���.....�U;. _—
<br /> its use di:�aiiinuecl�-vit,`�in ten monri�s o�`rec eipt ui rhrs noiice ur vvrfhin a siiater pened ii iaiuir�l by Iecal aJinance.!i the system is iailrny to p�cieci`yrcwnd
<br /> wafer,the system must be upgraded,replaced,or its use discontinued within the h'me required by fecal oirlinance.If an existing system is rrot failing as defined in
<br /> law,and has at least(wo feet of destgn sdl separation,then the system tte�d not be upgraderl,repaired,replaced,or its use dlscontinueci,notwrthstandirg any
<br /> local ordinanc�that is more stnct rhrs provisron does not apply to systems in shoreland araas,Wellhead Protection Areas,or those used in aonnection witl�faod,
<br /> beverage,and lodgfng�blfshments as defrn�ed in law.
<br /> wq-wwists4-31 Comp(i�ce Inspection Form for Existing SSTS
<br /> 4/1/08
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