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, � D�- �p �i"�� �� <br /> � � <br /> � ����.��;� tu�innesota Pollution �,Ot11�J�laIICE �t1S�eC�lt?I�l ���'11'1 <br /> ������ Cor�trol Agency <br /> 520 Lafayette Rnad North Existing Subsurface Sewage Treatment Systems (SSTS) <br /> SL Paul,MN 55155-4194 Doc Type:Compliance arrd�Entorcement <br /> , __-- _...._ _..__. <br /> InspeCtion results based on Minnesota Pallution Cantro!Agency(MPGA) � For local tracking purposes. <br /> requirements and attached forms–addi�onal locaf requirements may also apply. <br /> Submit completed form to loca)Unit af Governnnen#(lUG}and system owner <br /> within 15 days " <br /> System Sta#us <br /> System status on date(mm/dd/yyy}►}: 6/24/�^016 <br /> � Compliant—Certificate of Comp�iance ❑ Noncompliant�- Afatice of Noncornpliance <br /> (tfalid for 3 years from repart date, unCess shoeter time (Ses t/pgrade Requirements orr page 3.} <br /> frame outlined in Loca!Ordinance,) <br /> Reason(s}for noncornpliance (check atl appticab}e) <br /> ❑ Impact on Pubfic Healih(Compliarrca Companenf#1}–fmminsnt th�eat to public health and safety <br /> ❑Other Cornpfiance Conditions(Camplrance Component#3)–Imminent threst to public health and satety <br /> ❑Tank Integrity(Compliance Componsnt#2)–Feilrrrg[o protact groundwater <br /> ❑Other Compliance Conditfans(Compliance Component#3}–Failing to protect groundweter <br /> ❑Soil Separatian(Compfrancs Corraponent#4)–Failing to protect groun�ater <br /> ❑Operating permiUmonitoring plan requirements(Compliance Component#5)–IVoncompliant <br /> Property Information Parcel I[�#or SecJTwp/Range: 221172324�49 <br /> Praperty address: 71Q Big lstand, Orona Reason far inspection: LGU Requirement <br /> Property owner. C Net�ent 8�Leslie Neugent Qwner`s phone: <br /> ar . .... _ .. _ <br /> OwneYs rePresentative: ____� _,w� Representative phone: <br /> l.ocal regulatory autho�ty: __._� Regu{atory authoriiy phone; <br /> Brief system description: <br /> � _ _ � .� � <br /> Cotnme�rts or recommendations: <br /> Certification <br /> 1 hereby cae�tify fhat all the rrecessary infornrstion has been gathered to determine the complience status of thrs system. !Va <br /> determination of future system performance has been mor can bs rrrade due to unknown cond�rons during system construcCion, <br /> possib/e abuse of the system,inadequate mainte»ance, or tuture water usage. <br /> Inspector name: Paul 8rand2 Certification number, 5182 <br /> Business name: Soil!nv ' n& nc. ucense number: 3263 <br /> lnspector signature: Phone�umber 651-260-3T83 <br /> Necessary or Loc Required Attachments <br /> �Soil boring logs � SystemfAs-built d�awing ❑Forms per local ordirtance <br /> �Qther information(list): Manufadurer's checklist <br /> _ __._ . . — � .._... _� ,�e_______ <br /> www.pca.state.mn.us • 651-29G-6300 • 800-657-3864 • T1Y fi51�282-5332 ar$QO•657•38fi4 � Available in a�ternat�ve formats <br /> wq-wwrsts4-3tb • b/4l14 Aege f oj3 <br />