|
05/27/2011 62: 21 7634975011 SPTESTINGINC PAGE 04111
<br /> i
<br /> i �
<br /> ,a . Nuinn�s�i;cl F�OIIUtIUtI , C�mpl�an�� In��ec��or� �orm
<br /> �� ��mtrol A��ncy �
<br /> Ec�A��png Su6surface �ewage Yre��kn�en� �ysl�e�ns (SSTS) �
<br /> 51p Lafayelt�lioad Nor�h !
<br /> St.Paul,MN 5�155-�19�1 D�c 7ype;Compllence and F_ntor�em�nf
<br /> � I�s�hruckions on page 6 j
<br /> S�lJ1'�1A�'Ic��/ �01'98'� {Complek�d form must be submilted to#he local unii of go�ernment within 15 days.)
<br /> Parcel number:
<br /> ...------ � - .. �i,, _ ...
<br /> .. . _ .. ,
<br /> System status: � Compliant ❑ Noncompifant� rnr Local tracking Purpose�: �� �� �— ' '
<br /> (based on all .r,�mpllanco requiremenfs)
<br /> !
<br /> Property Informafiion I � ��- "�--- ---- "
<br /> I'roperty owner name(s): ��L,�_ H.�.Y�!G�;�_��.L�� pro ert owner hone: „q,�7�, •
<br /> p v P _.4��_.9�0'�;
<br /> Prc�perty address: . �L.-- ' G �����• D'�s7�ti;0
<br /> �I�.�,Ps7_... 1�1
<br /> Prop�rty owner�ddress(��diff9rent):__,.,.._ �--`�-_ ---,..'----- -.�_-._..._�
<br /> County:_�_�i�.0�S����_ �Permitting authority: G��� D�O�O �
<br /> -- --... .�---, _.;
<br /> Date syat'em constructed: _,�°�r�� Reaso�fo�Inepection; ZO�Q'��.�Q�.�,�,c,�✓�p�
<br /> Sys�Q:enn ID�scriptic�r� ;
<br /> B�i�aF system descriplion: .a.�l i2� ��._��'1G'`�1��s_`.►�����1_Z►r__w�r.�ravnr���,�.co��n:.,.1_u��S.s9�s�
<br /> Lacel permit number: ____ __ ___ Number v'F bec{roomg; __� _ Dosign flow reto: (opp
<br /> Ys tl�ie sysi�em: "—
<br /> In Shoreland area? �
<br /> I�Yes � No In V1lellhead Protect�lon Area? ❑Yes [� No
<br /> An U_S_Environmental Protection ; Sysiem servinfl a Minnesota Deparlment
<br /> Ngency(�PA)Class\/Injection Woll?[]Yes � No of Heath(MI7W)Ilcensed facility? ❑Yos �j No �
<br /> CO�YIp I�811�:e S�d�US (13ased on state requfrer�nonfs-edditionel local roquirements may also apply.) I
<br /> Based on the informaiion gathered and reportedjon attached forms, the compliance status oi thls system is(chodc one):
<br /> �Certificate of C�mpUenco-valfd until (3 yea�'s iYnm date of►�pn�t):
<br /> ❑ Notice of Noncompliance�For Noncompliantl systema: � ��� � '�
<br /> The reason for noncompllance is: __i__ _
<br /> This nancompliant syqtem is classlfYed'as(check onc balow); ���� � —'
<br /> C_�I Imminent threet 10 public health 8�sa�ety [] Failing to protect prourtd water ❑ Noi in compliance with operating permit �
<br /> C2r�1f�Cd�iOn
<br /> 1 hereby cartify thal all the necessary infnrtnalVori has been gaf.h�red l�detelmine the compliance stAtus of this system, No
<br /> dotem�lnation of ruPune system performance hes�beon nor can be made due fo unknown con�itions dudn�sys#em conskrucPlon,
<br /> possible abuse of fhe syst�em,fna�lequate mafnt nanc�, or hilcrr�e uvater usat�e_
<br /> Name: ��'�'�l/'� .� 1l. __ � � �.�', - � —1�,�.,.,..�_er _�2�r�,,�_,.._
<br /> �' �?C,._,_..... 1..
<br /> �--._'_.�-...;.:._�.a_I_�_1,,.1�"�- h� _ _ Certificaiic,nnumb
<br /> Buslness Ilcenso name and number; S_;�'.��( 5����..1,�a � � �� �� '[�.�k'r ,�' ,^�_��ry`�r,�, or
<br /> Name of local unit of govemmPnt: � �
<br /> _._.
<br /> � _._......... ._.,..—
<br /> —•---. ....
<br /> Signaiure: �.— � J � —�r--,...— --.� ,
<br /> �
<br /> __.._.._ _� __ �---�._.., ...._ -._._._ Date: _�!i��'�.. t?►J . I
<br /> Required Attachments � �
<br /> �] Flydr�ulic Perfo�mance T�nk Integrity [J Operating Permit Fo�m(if a�plicable)
<br /> a" 5oil Boring L�gs � Soil S�peration
<br /> n Syst�m drawing/As-built drarnring ❑ Ahy local requirements that are difFerent from what is requlred ott this form ;
<br /> (]Other fnPormation (lisl;): _„___ �
<br /> ...__..... ...._� -----.....--- .. _.....------........_ .
<br /> Upgradm 9�equiremQnts (de►ived fi+,�m Minn. St�t�§ 9'15.55)An Imminent threat to pt�bllc heallh end sa�°oty(lTAFIS)must Ue upgr�de� ~
<br /> .�pleced,or it5 usa dlacontiiyuod wlfhin ten months af►�Ceipt of thls nptice or wlfhin a shorter period!f r�quired 6y/ocaf prtiinence. IF the syqtem!s
<br /> f�lling fo�rotec!g�aund wt�t�r, the system must be u�nc�r�dad,�apl.�ced, orJla use dlsconflnued w/tlfln Ihe time r�qulrad by I�r,AI�rdinai�cs. If�n
<br /> existGic�systAm is not falling As daflned 111►aW,t�nd has aM lesst hvo�ef of doslgn soil seperatlon, then tl�o syqrem nood nod be upgradecl,rcpaiied,
<br /> replar.ed,orits uss dlscontinued,nofwithstanding eny loc�31 ordlnanr,e diat is more st►icL Thls provlslon does nol eppfy b systoms in shorr�land
<br /> �reps, Wcllhead pratection Areas, or�h�se�ised in connbcflon with food,beveraqe, And lodginq establishments as del)rled In lew.
<br /> .,..._ ..... .
<br /> wv�w.pca.stake.mn.us � 651-Z96-6300 800-657•3B64 • TfY 851-2R2-S337 nr AM.Rti�.ia�a . A��o�lehln i� ���,,.�.��._r_.___��
<br />
|