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05/ 9 14:20 9528733112 PAGE 61/69 � minnesota Pollution Compliance Inspe�tion Farm • Control Agenty SZO�afayetteRoadNorth Existing Subsurface Sewage Treatment Systems (SSTS) St.Paul,MN 55155•419q instructions on pag� ' Parcel number For Local Tracking PurposEs System status; Compliant 0 Noncompliant (based on aJ!com Ir ce requirements) Summary Form Property Information Property vwner name(s): �, r` S' � ---.._...._,. ._ .._... Property address; � � ,.....----... ....._... ---� Property owner's address (if dlfferenq: COun � - • - ---..._. ry= Pro erty o ner phone; Permitti g authority: Date system const ucted; � t�? Reason for lnspection: �jQ _� . System Oescript3on Brief system descr+ption: ��"G1,/'�f'�-� ►�� (.Q r�l �ocal pe�,nit number; umber of bedrooms: � Design(low rate; __.. �j� . Is the systam; `� In Shoreland area? Z�L Yes ❑ No In Wellhead Protection Area? ❑ Yes �No An U S, Environmental Protection �—` 5ystem serving a Mlnnesota bepartment Agency (EPA)Class V Injection Well?❑ Yes �No of Heath (MQH)�icensed facllity? ❑ Yes �No Complld�Ce Status (6ased on state requlrements-additional local requlrements may also apply,) Based on the information gathered and reported on atteched forms,the compliance status oi this system is(check on�t �ertiFicate of Compllance-valid until (3 years from dete of r�portJ; ___`__ _ ❑ Notice oI Noncompliance- Fo�Noncompliant systems: 7he reason for noncompl;ance is: This noncompllant system Is classlffed as fcheck one below): ' � ❑ Imminern threat to public health& saf�ty ❑ Falling to protect ground water ❑ Not in compliance with operaung per�r.� Ce�tlflCdt10t1 (Completed form must be submitted to the local unit of government within 15 days.) !hereby certify fhaf aU the necessary informarion hes been gathered fo determine the compllance sfa�us ol th�s sysr�n� r�� determinafion ol luture system per�o�mance has been nor can be msda oue to unknown conditions durrng systern ca�sr��c;,��. possible abuse o!the system,inadequ fe m�inlenance, oi future weter usage. Name: __��,��b�►('��)�,(� Ce�tification number. ��,p�j� Business license name and number: ��,�� SQ r�J I1.25 ,�L ��Qot __...__._. „ „ or Name of local unit vern t; _ _,�. __ . 9 . _ Signature: Date; �� Q Required Atta�hments Inspector Complete: This Inspection Report is J`� pages long. Check compli�r�Ce fom75 attaGhAd: Q�draulic Pe�ormance�Tank Integrity�oll SeFaration ❑Operating Perm��F�rrt,� f applicable) �,ystem drawing/As-built drawing ❑An assessme a�y local requ e nls that are diflerent from whai�s req��rea on i��s lorm ❑ Soil Bonn'g Logs ❑Abaneonmenl fortn(if approprlate) ❑Other intOrmation(1�31): Upgrade Requirements (derrved frnm Minn. Sfaf. § 115.55)a�imminelif N1rt+al fo public heaph ond saltty(IrPHSJ musl De upgiaoeo.reo�acec : �ts vse eJseonunued wilhi��sn mon�h�of�ece�pl o/IAis�ofin o�wifAin�ahohei penod�I repuired Dy locel ordlnance,/1 fAe sy,ster�r�s lad�ng ro orolecl o�a�rc waler,IAe sysfem mvs(D�uppr8dsd,repl�ced,or Jts use eiseont�nued wilhln fne Gme repulred by loca!ordine�ce.ll an exislinq syslem�s no�I.v��.n<<5��;'r.=, • low,and has al lees!Iwo lee!of Cespn soil separal+on,then fhe syelem nCed nof De upgre0ed,repei�e0,reD�acad, or its use O�sconnnueC.no;�v;rrs�,ar:=.::;;-, �ocar orainence f�af is more slr9cl. Th/s provlsJon Qoes nol a0p�y�o sysiems�n s�oreland arees, WNlneqd Pro(eclion Arees,oi�nose used��;orT.�a;�,;r„;�• • oeveraoe, and looginy esfabliaAmen�a as de/lned in law `�' wq-wwis[s4•31 Compliance Inspection Form fo�E.��S;;ng SSTS .�� .,e