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63/14/2069 0'1:21 7634975011 SPTESTINGINC PAGE 03/69
<br /> �:;;�..,,:�..�;;�,. Niinnesnta Po lutia�i .
<br /> �ra���r�����: ControlAgen � Compl��nce� insp�cfiivr� �'Qr
<br /> m
<br /> 57,OL,at�ye�t�teRoad arth �xo�t7hg :�ubsurFace S�e�ragle "�"r�atrtt�n�t Sys�ert�s (SST�)
<br /> 5r Paul,MN 55155-q gq
<br /> Instructions on pa�� 7
<br /> f'Rr�el number;
<br /> System status: � Com Ile t �� For Locel Y��cking Purposes:
<br /> P ❑ �loncompifant
<br /> (based on all campliance r�q� rements)
<br /> Snrrmn�airy Fv�r�
<br /> Pro�erfiy Informat9on
<br /> property owner n�me(sy; �ovv �_S A�R C s
<br /> Properly address: �t �O �,�„t��`�_G��� ,��� � '--�^_ .
<br /> Property owrter's addr�ss(f d�►r�rent): `�'�`�"� --
<br /> Counly:,���_�, Prop�Fty ownar phonr�: �SZ—y49 .-9e��� Permittln � �
<br /> �, g authoriiy: _,O_�.�Q
<br /> Date system con�tnicted: _ .�(o - �.�_ ��ason for In3pectlon; �
<br /> Svste �C�'�''_�� ��r6"�.^,
<br /> rr� IDescriptlon
<br /> Cirlef system descriptfo�; __���,,�� �� ,�\� �
<br /> '�.—.�,,00��?�a�G�t"ti'SS s L�.�"SC��O�5'S�
<br /> I_ocal perrriit number; _„ � . Number of bedrvoms: � ,����
<br /> - ��L D�sign flow rato;
<br /> Is the system:
<br /> In Shoreland area? []Yes � No ln Weilhead Protectlon Area?
<br /> An U.S. �nvironmental P tection ❑Yos �No
<br /> Agenr,y (EPA)Class V In ction WeII? Yes System selving Ei Mlnnesota Department
<br /> j ❑ �No of Heaih (MDI-I) licensed fecility? I]Yes � No
<br /> tomp�ianee Staxus �ea �d on state requirements,addltlonal local�equir�ements may also apply.)
<br /> Dased on the informatlon g ther�d and reported on att�ched forms,the compllance status of thls�ystem is(check ona);
<br /> [�I Certificate of Compllanc -v�lid until (3 years ri�om dale of ieport);
<br /> �Notice of Noncompllanc -Fo�Noncampliant syetems:
<br /> 7he reason for nonco pli��ce Is:
<br /> 7his noncompllant s sterr� Is classifled a�(chack on�helow); � �� � ' �--
<br /> ❑ Imminent threat to ublic health 8�safety ❑ Failing to protect groun�i water ��
<br /> ❑ Noi ih compliance with operating p�rmft
<br /> Cel'ti'��Cd�10t1 (Completed form must be submltted to the local unfl of government withln 15 days,)
<br /> I he�eby certify tliet all�he n cessary lnforma�fon lies been gatherod to dotenr►!ne fho compliance sfefus of thls system, No
<br /> deferminetlon of fufure sys m per�ortnance 1►as been nor Gan be made due tc�unlrnown condlilans durfng sysiem c.onstri�ction,
<br /> poss1610 Abi.�se of the syste , inadequate me;ntenanca, or fuft�re wafer usage.
<br /> Name. ������ C,'��
<br /> ���— �'L'�M���"�� Certifir.Ation number: .����_
<br /> fiusiness license name and number: S -� ' ����+ L,�,�� �� �-
<br /> . ,��/�"��L �_._} .?�'-����.��Cfa,, or
<br /> Nam�of local unit ot gover ent:
<br /> 5ignature; ��"�---� ,�.......�----.- '—_ " , ,.—
<br /> - _ .— _,— Date: _� �? .-�1 -O�1'
<br /> Required Attacliment Inspoctor Gomplete: This Inspeefilon Report is � �
<br /> ChQcGc complianCe fol�ms 1',t�chad; IN�Wydraullc PerFormance pa�os lohg.
<br /> eppllc�ble) I�System drav, n /As-bullt dr��Mn �T�hk Inleg�ity �•Sall Separet�on ❑O�ereting Pocmit forrri(If
<br /> 9 g �An aseessmen!oF any local requiremants that are dlfFerent from whal I&requlred on thl9
<br /> Form �Soil Boring Loge Abaridanment Porm pf approprlate) ❑Other I�Formatlon(Ilat):
<br /> U(79��de REqUIrClllet7 � (deyypd finry�Mlnn. Stat.§115.55J qn/mminenl tNreef to ppGl/c I�oe/fh a��d aefefy(/TPHSJ mus�be upgre�(ed,replaced,or
<br /> !fs uFC dlscp/lf/nued Wlfhln(eh onfl�s o/rece/pf ol thls qotica or W(thln y Shoder per/od if requU�ed by local ordln6nce,!f fhe sy6tem Is f�+J!!ng to protee!ground
<br /> wafer,flro sysfem mu�t Ue upg ded,replaced,orlfs use dlsconflnuod wllhln the l/me requlred qy locel ortllnance.ll An ax/sflny system/s not Palling as tlellnod!n
<br /> lew,�fnd hAs At le9�st lwo foo�o doslgn soJ!sapernflon,then fhe syslem ne9d not be upgrAded,repalred,rsp�aaed,or IfR use dlsconGnued,nolwnhstending 9ny
<br /> roce!ordinr�nce fhnf Is more st�J f.Thls provlelnn poes no(app/y(o sysrems In shorelen�flreas,Wellhe��p��eoGon/Iroes,or fhose ueed In cpqhedfoe w/yi/ood,
<br /> beveMpa,ahd 1odglqg estab!!Dh ents es Oe�ned In loW.
<br /> wq-wwisEsQ•31
<br /> �/f/08 Compliance Inspection Form for Existin.¢55T5
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