|
08/18I2010 01:20 7634975011 SPTESTINGINC P�GE 04/08
<br /> � MinnesotaPollu�tion Compliance Inspect�on Form
<br /> �'�,;y;' Contro) Agen�y ExOsting Subs�urface Sewage Treatim�r�t Systems (SSTS)
<br /> 52(16af�yehe Road Nor�h
<br /> St.Paul,MN 55155-41�4 Doc rypo:CumpllancQ nnd Enfo�ment
<br /> Instruc#ions on pege 6
<br /> Sl8I1�111a11'�/ FOY'AXI (Completed form must be submitted to the local unit of government within 15 days,)
<br /> Parcel number;
<br /> System stalus: [� Complleni�(] Noncompliant �or Local Tracking Purposes:r�� � �� ��
<br /> (based on all compliance requl�ments)
<br /> propert� Informa�i�on
<br /> Property owne�name(s): ,.�0_�ly1J �r I-1 ��(_L_�..,.,.,,,,_,,,.___, .,._�.—._ Property owner phone: `� 5 Z�'a,y�7�y�o��_
<br /> ,,.,. _
<br /> Property address: 7 3_5�'�'�4'A 1.'�G�����• . D'� �1 O. _,.....�._._....__._...—_......._.`
<br /> _.—.___._ �,.__....,., ,p.�.._
<br /> Properly owner eddYess(if dlff&reriy: _.,�_.__ _
<br /> County:�_�Gba�1'�IA�..:..,..-- Permltlfng authorlly; __L_I�`�...._v.�._.C74�c7�� --•-
<br /> Dal'e systQm constructed: _ � � ��I ,,,_..____ Roason for inspection:��F����'��� K
<br /> System De�scriptiot�
<br /> Brlefsy�tPmdescription: a��i�o0�1��G�.�.�hyx_h..-�-L�oo,�,y13wv� �tlit4vvt��9'P��.w�o.� a�C,�,��k�-�'►o�,� �¢ot;��s
<br /> �oc�l permit number: _� ,___ Number of bedr�omA: _ _ Design flow rAte: ,
<br /> Is th�system:
<br /> In Shorelend area2 f�Yes ❑ No 1n Wellhe�d Protoction Are�7 ❑YQs � No
<br /> An U.S. F_nvironment�l Protection System serving a Minnosola Department
<br /> A,ge�cy(EPA)Cl2ss\/InJecliorl Well?�Yos [�No of Heath(MDH)licensed faciliiy? ❑Yes � No
<br /> � C0111p�1dIlC@ $tdtUS (Dased on statc�neq�dr�ments-edditlonal locel rieqciirements mey also apply.J
<br /> Besed on the informativn gathared and reported on atlached fo�ms,tha❑amplianco stakus of this system Is(check one):
<br /> � Ceriificate�f C�mpli�nce-valid unill (3 years finm d�fQ of rr�port): T
<br /> ❑NoGco of NoncoMpliance-For Noncompliant syatema:
<br /> The reason fo�noncompliance is: _�,,.,�_,..�_�.___,,,...�,— __...— — ,
<br /> Thls non�ompliant�yst�erri ia clasalfled as(check ane below):
<br /> ❑ Imminent ihreat to publfc health 8� s�faty I] Failing to prolect ground weter ❑Not in campliance with ope�ating pennil
<br /> Certif�cat��on
<br /> 1 heneby cerll�y tlial aI!llie necessary informalfan has been getheied fo deformino the camplfance st�lus r�f this system.No
<br /> detorminatlon of future system performance I�es heen nor r,an be mad�due to unlsnown condlllons d��ring syst�em conshuc�lon,
<br /> posslble&buse of(he system, lnad�quate melntenancQ, or fi�h�►a water usa�e.
<br /> Name: ��!''�i1.� ..N.,:waC.�.J -1 �:..��,.,.. ----. — Certliir,allon number� __Co'�� y,m.,
<br /> B�aslness Ilcense neme and numher. S -'� �5'SC'!`r_S'_I_LJ�:,J�G . �-l�3`��),�,�1����`3�L�.�aLk� �r
<br /> Name of 1oc21 unit of g�vemmen � _ , __,,,_,,,,�,,.__ ,
<br /> Slgnature: 7. ._��- ._....._..,...., _— D2te: _`�_����a�--.--
<br /> Required Attachments
<br /> �Mydrau►ic Performr�nce �Tanlc Integrity ❑Operating Permit Form (iF applicab�o)
<br /> Soll eoring Logs � Soil Separation
<br /> � System drawing/ns-bullt drawing ❑Any local requirements that aro dlfferent from what is requlred on this form
<br /> ❑Other informetion (liat): ,_ ,,,,,,__ �.,_ �„
<br /> Upgrede Requirements (derivad rYom Minn. Stat.§ 1'J5.55)/1n Imm►nent thr�af to publlc l�aalfl►and srallety(ITPHS)must be upgradad,
<br /> neplaced,or its usR�lisconfinued w!lhln fen months of recelpt o�thls nollce or within a eMorter perivd if ir,quired by locel ordlnonca.If If�e�yg�m(s
<br /> falling lo protcct ground water, the ay5fem must be up.qraded,replecsd,orlts usv disconKntred with/n the time raqulrsd by local oidlnance. If en
<br /> exlsflnc7 system is noF fellfng�s dellned ln law, and l�as at leost two feet of design qofl saparaUon, U�en tlio sysiom need not be upgradod,repelred,
<br /> replaced, orlts use dlscontlnued,notwltfisfanding eny face/ordlnence that Is mo►e strlct. 7Nls proVf5lon does not�pp/y fo systems In shoreland
<br /> �ns�s,WelNteed nroFer,�ion Areas, or tfiose used in cflnnecflon w111i fbod, bmvc+rage,and lodping establishments es de0nad In law.
<br /> Www.rta.skaCe.mn.us • 651-296�6300 • 800-65i-3B64 y • TTY 651-28Z-5332 or 500-657-3864 • Available in allemativr formats
<br /> wn-wwiereA-a1 . A17�1(1a Pnoe 0 nf A
<br />
|