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, <br /> u3/15/2016 12 24PM FA�; 9528733112 �0001/0004 <br /> �,:.,.�.,.. <br /> ������;°,��m Minnesota Pollution �o���»nce Ins e�tion Form <br /> �,?.,.� � <br /> "=J Cantrol Ayency <br /> szo�afayecce Road tvorth Exist�rtg Subsurface Sewage Treatment Systems ($$TS) <br /> 5t.Paul,MN 55755-4i94 Doc Type:Compliance and En7proemenf <br /> 1118pection results based on Minnesota Pollution Control Agency(MPCA) For local tracking purppses: <br /> requireinents and attached Gorms—additional Iocal requirements may a{so apply, JU� � '� �o�� <br /> Submit campleted form to Lo�al Unit of Gavernment(LUG)and system owner <br /> wlthtn 15 days N <br /> System Status <br /> System st�tus on date(mm/dd/yyyy); 3/10/2016 <br /> � Compfiant— Certificate of Cvmpliance ❑ Noncampliant�- Notice vf Rloncompliance <br /> {Valid for 3 years from repo�t dato, unless shorter tr'me (Sec Upgrade Requ;rements on page 3,J <br /> fr�m�ouflinecl In Locsl Ordinance.) <br /> Reason(s)for noncompliance (check al/appl;cable) <br /> ❑ Impact on Public Health (Compliance Component#1}—ln�minent tl�r�af to pul�lic h�alth and safety <br /> ❑Otlier Compllance Conditions(Complisnce Componen!#3}--Imminent threat to public health and safety <br /> ❑Tank Integrlty(Compliance Compo�ent#2)—Faf!!ng tr�protecf groundwster <br /> ❑Oiher Compliance Conditions{Compliance Component#3)—Failing t0 protcct groundwater <br /> ❑ Soil Separation (Compllanc�e Componenf#4)—Farlrng to pratect groundwater <br /> ❑ Operating permiUmonitoring plan requirements (Compliance Gomponent ti5)—Noncomplisnt <br /> Property Information �,� ��,�J parGcl 11��or SecfTwp/R�nga: �(�� I t�j_�3 - �� .�,�,�� <br /> Property address: 515 Ferndale Rd North,W�ap�a#a, Mn 55391 Reason for Inspection: Sale <br /> Property owner; Bob and Kim Griffin �wner's phone: <br /> or - �- <br /> Owne�'s represenlative: _ _ Represent�tivo phone� <br /> Local regulatory authority: Hennepin County Regulatory authority phone� <br /> Brief system description: <br /> Comments or recommendat(ons: �- � -- <br /> Mound system shoufd remain cleared ofi. Grass is best cover fpr thc system and it is recammended thaf any trees or shrubs be <br /> removed from the mound. <br /> C@f t1�1Cdt1 OIl <br /> 1 heneby certify fhat a!!the necessary information has been gathered to defermine the complrance status of thrs system. fVo <br /> defermination of future sysbem performance has baen nor can be made due to unknown conditrons dunng system construction, <br /> pnssib/e abuse of fhe system,inadequate malntenance, or future water usage. <br /> Inspecto�name: Josh Swedlund CertificaUon number. C1659 <br /> Business name: Swedlund Se tic Service � !� License number. 2502 <br /> Inspector signature: �-�� � u�/\ Phone r�umber: 952-873-3292 <br /> Necessary or L.ocally Required A�chments <br /> �Soil boring Iogs � SystemlAs-built drawing � Forms per local ordinance <br /> ❑Other information (Ilst): <br /> www,pczt.state.mn.us • 65t•296•6300 • 800-657•3864 • TTY 651-262-5332 or 8D0•657-3864 • Available in alternative formats <br /> Wq•wwists4-39 . 3/1bl f2 <br /> AGgefof3 <br />