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11/05/,2015 12 :22PM FAX f�0001/0004
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<br /> 4� � Minnesota Pollution • '
<br /> � � � �ontrolAgency ��mpl�anc�e Inspect�on Form ` ;
<br /> 520 Lafayette Road North ���ting Subsurtace Sewage Treatment Syste�ms,($STS);'; ."`
<br /> �I t.Paul,MIV 55155-4194 Doc Type;Compliance and Enfolae'ment
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<br /> Ins ect[on� results based on M[n Fpr IoC�I tr�r
<br /> p nesota Pollut�on COntrol A enc MPCA �L� : �
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<br /> requirements and attached forms—additiona!local requirements may alsp apply. �+y� , i, (
<br /> Submlt completed form to Local Unit of Gavernment(L U G)a n d s y s t e m o w n e r N�� �5 20�5� ' I
<br /> within 15 days
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<br /> Syste�m st�tus on date(mm/dd/yyyy): 11/�/2014 . ;
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<br /> � Corripliant— Certificate of Compliance ❑ Noncompliant— Notice of Noncomplian'ce ' ' ' I
<br /> (V a l l d f o r 3 y e a r s f r o m r e p o r t d&t e, u n l e s s s h o r t e f t i m e �: y ' � >. '� � `
<br /> (See Upgra de Requirementa on p�ge 3.) ,,,_ �
<br /> frame ouflined in Local Ordlnance.) �
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<br /> '� Reason(s)for noncompltance(check al!applicable) _: ;
<br /> ❑Impact on Publfc Heafth(Compliance Cpmponent#i)—Imminent threat to puhliC health and safe(y �'
<br /> ❑�Other CompElance Conditions(Complisnce Component#3 —Imminent thr� ° `-: �
<br /> ) st to ublic health and
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<br /> ❑!Tank Integrity(CompGance Component#2)—Fai/ing to pro(ect grounrlwater '�
<br /> _ ❑�Other Campliance Conditions(Compliance Componerlt�13)—�a�ling to protect groundwater
<br /> ❑'ISofl Sep2r'ation(Compllence Component#4)—Fgiling to protect groundevater
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<br /> {]IOperating permiUmonitoring plan requirements(Compliance Component#5}—Noncompl;ant
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<br /> "` Pro ert Information j �
<br /> f �' .' � yl Parcel!D#or SeclTwp/Range: ,.. :
<br /> Property address: 425 Ferndale Roed North Qrono Reason for in8pection: Sale
<br /> Property ow�er. Le0 Hause�Estafe OwnerB phone: 612-309-6332 �
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<br /> Owne�s rep�l-esentatiV�: Represent�tive phone: � :
<br /> Local regulai ory authority: City of Qrono Regulatoty authority phone: '
<br /> Brief system description: 2',1Q00 &I se tic tanks, 10fl0 allOrl um tank&4 bedr0om mound s stem ' �
<br /> Cornments br recommendations: � { '"
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<br /> ��� Certification ���, �� :���� ���,� � �����
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<br /> I hereby cerfify that a!1 th�necessary information has been gathered to determine the campliance status of fhis system:No
<br /> determination of futur'e system�Iperformance has been nor can be made due to unknown conditinns during system construCtion,
<br /> " possible ab�se of the system, inadequate maintenance, or futu�water usage. ,
<br /> Inspector name: Josh Swedlund Certification number: C1659 � � "> '��
<br /> Buslness na�ne: Swedlund �e �c S License number: 2502' ' '" `7 , '
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<br /> Inspector signature: Phone number: 852-873-3292
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<br /> Necessary or Loca Iy Requfred Attachmen s
<br /> 0 Soil bo�ing Ipgs �! �System/As-built drawing � Farms per local prdinance ;,
<br /> [] Other information(Ilst)' � ' • t ; �
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<br /> www.pca.state.mn.us • 651�,'246-6300 • 500-657-3864 • TTY b51-282•5332 or 800-657-3864 • Available in altemativ�focTriats::i::_::i
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