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1110512010 03:55 7634975e11 SPTESTINGINC PAGE 66/16
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<br /> ,a , �e►,nesot�� ����ut►�n Co►mp(�ance �nspP�t�ion Forrr�
<br /> �� ,;:,,� Cv�ntro( Anen�y
<br /> Ex7s#qng SubsurFace 3ewage '�reatment �yst;Qrns (SS1�S) j
<br /> S20 LaFayel°t�Road Nortl�
<br /> Sl,Paul,MN 55155-n194 Dac Typo�CpmpUance And�nfor�emant I
<br /> Ins'�ructions on page 6 I
<br /> Sumrn��y Fb��rn (Completed f�rm must be submitteq to the local unik of government withln 15 days.)
<br /> Parc�l number: '
<br /> ------.. _._..--- -�.. - --�..,..
<br /> , __... ,..,_ .
<br /> System status; (� Compllant ❑ Noncompliant For Local Tracking Purposes: --
<br /> (6ssed on all compliance r�quirements)
<br /> _.. �--�-,:. _._...,.. ---�-
<br /> Prope�rty Inforrnati�n -- `-- ;
<br /> Proparty owner name(s): �q¢�y� �p»,�,�p� __ Pro ort owner hone: �
<br /> P• Y P �eJ Z_'.1�^13�5�F_i
<br /> Propar#y address: a.'a.,,.s� '��.1��, 4'��� �y�2f�-�. U?-c75,cQ �
<br /> � ---- �— -,,.,.__ _...._ _...
<br /> Property owner address pf dlffAr�nt); _ „ - '�--�
<br /> - ,,._ _..,
<br /> County:�.k�y��v�� Permittin �u4horiiy- L� p� _ -----����- '
<br /> ,, .._
<br /> 9 • ��—_�4-O,�o _.... _. --i
<br /> Dato systern constructed: (o-���_�� Roaeon for insper,tion;��..( .� ,�e�,��__
<br /> �— .._—,..
<br /> 5ys�tem mescription i
<br /> Brief system description: ���oc�_ 1_���-L�y�, �o���c���3�o�►�+�...,__ �n �
<br /> 5"'- t--- �k�a��'�c_s�"�� myU���l
<br /> I_oa�l parmit number: _ __ Number of bedrooms� Design flow rqte; '
<br /> ----....--- --S-. —�.5�—.... __. �
<br /> Is th�system: �
<br /> In Shoreland area4 �
<br /> �Yes ❑ No In IAl�llhead I�rotoction Area? ❑ Yes � Na
<br /> An U.S. Environmental Prot�ction System serving a Minnesota Dapartment
<br /> Agency(FPl�) Class V lnjedic�n INell?� Yes � No of Heath (MDH) lironsed facility? �Yes I� No �
<br /> COfl'1PI1�nCe $tdtUS (Baso�d on stete r�quirements-eddl�ional locel requiromenfs may�Isv apply.) '
<br /> Based on the information�athered and reported on attaclied forms, the compllance status oi thls syst�m is(checic one):
<br /> I� Cortificate of Complia�ce-valid until (3 yeers ili�om data of repo►t): �
<br /> ❑Notice of Noncomplf�nce-For Noncompllsnt systems: �
<br /> The reason for nonrom Ilance is: ,
<br /> ❑1lmminent hreat tci ypblie health 8 safetag c �ailin �to bro e..,, . ., ... _, ---- ..
<br /> ' - � W�. _,..._I
<br /> P Y ❑ ' g p t ct ground wAter ❑ Not in compliarice with operatlnA permft I
<br /> Certif�cat�on
<br /> I here6y co�tify thaf all th�nr�cessary inf�rmafron hes bean gather�ed to detelminv the compllance stafus�f this sysl�em. No
<br /> detormination of fi�ture systc�m perFormc�nce Nes been nor can be made d�ie b unlcnown condltlons during system construr,tion,
<br /> possible abuse of the system,Inadequate meintenance, �r fi�ture water ussgQ. ;
<br /> Name: sr�/��,� .�j. _�G�1�Ny�'�•�.� __, ._ Ceriifiaationnumbef: �a;l'�
<br /> .. . ... — �----.. ,�.
<br /> Buslness Ilconse name and number: ..5.,::��"�'�y�y�)\�_.1,►J_j; , ��5�,..�...�.���_�41 W "1.�2�:�1''i..:)���,��LZ� or �
<br /> Name of Ivcal unit of governm�nt; __ __ _J
<br /> Signature_ ,��. _, .---::- --... _....,.. Dato: _..l,.1,.,�'_�_� � o�...,.,.. _. I
<br /> Required Attachments ;
<br /> � Wydraulic Performance �'Tank Integrity ❑ Oparating Permit Form(if applicable) ;
<br /> � 5oil Boring Logs � Soll Separation ,
<br /> � Sysk�m drawing/As-built clrawing ❑ Any local requirements that are different from �nrhat is required �n this form ;
<br /> ❑ Other infnrmatlon (Ilat); __ _ !
<br /> „ --- - ,
<br /> Upg�ade F�equlrements(derived from Minn. 5tat_§ '115_SFiJ�In Imminont tlirsat(o publlc hea/th and sal�ly(I7PWS)must be upgreded.
<br /> .repl�r,ed,or its use dlsconllnued withrn ten months af recelpt of thls noPlce or within a shorter peKod if required by lor.a/or►�Ilnance.If tho system is
<br /> falling!o pratoct grp��n�1 wat�r,tl�o system must Ge r�ppreded, rapleced, or I(s use dlsconUnued withln tho Ilme requ(red by lor,a/vrdlnance. lf an
<br /> exrsting system Is not falling as defined in I�w,and ha�ef least two fo�t of design AoH sAp4ret�on, Ihon the PyaFem n9ed not be upgraded, repal►gd,
<br /> nepleced, orits use dlscanfh�ued,notwifl�stending any loca/orrJlnane9 fhat Is mora strlct 77�is provlslon does not epply to sys(ems In shor�lancl
<br /> areas, Wsl!/ioad Prt�teCf/on Arees,or tl�ose used!n connectlon with food,bovarage,and lodging ost�hllshm9nts es deflned in law.
<br /> www.pca.5l'al'e.mn.us � 651•296-63�0 ^• B00-657-3864 � T7Y 851-2B2•5332 or 800-657•3864 � Avail�bl�in altemative formats
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