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05/22/2013 08: 45 9528733112 �� PAGE 01/04 <br /> 4 � `A <br /> i � r � J <br /> � IMinnesvta PaE�utiota �✓ � �' Comnl�an�e Ir�spection Form <br /> ~� Cor�trol Agency � ~ <br /> E�xistin Subsurf�ce Sewage Tre�'�ment Systen�s (SSTS) <br /> 520 Lafayette Raad North <br /> � 9 <br /> 5c.Paul,MN 55155-415�4 Doc Type:GomplianCe 9nd EniorCement <br /> IrlgpeCtion rOStllts based �n Minnesot8 PoUution Control Agency(MPCA) <br /> For local tracking purposes: <br /> requirements and aYtached forms-additional Incal requirements may also apply. <br /> Submit comp�eted form to Lacal Unit of Government(�UG)and syst�m owner <br /> within 15 days - - <br /> System Status <br /> 5ystem status on date{mmlddlyyyy): 5/17l2013 _. <br /> � Com�liant�Certificate of C�mpliance ❑ Noncompliant-- Notice of Non�ompliance <br /> (Valid for 3 years from repar�date, unless shorter time (See Upgrade Requir�menfs on page 3.) <br /> freme outlrned in Local Ordinance,) <br /> Reason(s)for noncompliance{check aJl applicabfe) <br /> � Impact on Public Health (ComplianCe Component#1)-Imminent thr�at to public health and safety <br /> ❑ Q#her Compliance Canditions(Cvmpliance Compone»t#3)-lmmrnenf threaf fo public heafth and Saiety <br /> ❑Tank Integnty(Compli8nce Component#2)-Failing to protect groundwater <br /> 0 Other Compfiance Conditions(Compliance Component#3}-FaiJrng to protect groundwater <br /> ❑Soll Separation (CompJiance Component#4)-�ar'ling M pmtect groLndwafer <br /> ❑ Operating permiUmonitoring pl�n requirements (CGmpllance Cornponent#5)-Noncompliant <br /> Property Information Parcel ID�#or Seclfwp/Range: . _ <br /> Property addsess: 1380 French Creek Dr. _ __ Reason for inspection: Sale _ <br /> Property owner� John Palombo _ Owner's phone- 952-428-8416 _ <br /> or <br /> Qwner's representati�e: _ _ _., Representative phone: <br /> Local regulatory authority: City ._ Regulatqry authority phone: _ _ <br /> Brief system description: __ _ - --- <br /> Comments or recommendations: <br /> Certification <br /> 1 hereby certify thaf alf the necessary�n��afion has been gafhe�d to de#ermine the compliance status of this sysfem. No <br /> detemrrnation of fulure sysfem performance has be�n nor can be made due(o unknow»condrfions dunng system construcflon, <br /> possible abuse of the system, inadeq�ate mainfen�nce, or(uture wat�r usage. <br /> Inspector name; Josh Sw d Certkficatio�number: C1659_ <br /> —. __ ... _ <br /> 8usiness name: Swedl e tiC ervice License number: 2502 . <br /> -- -..._ .. - <br /> Inspector qignature� Phone number 952-873-3292 <br /> Necessa�y c�r L cally Required Attachments <br /> � Soil boring logs � System/As-built d�awing ❑ Forms per local drdinance <br /> ❑ Other information (list): .,. _. - <br /> -- .....___ . _ <br /> www.pca.state.mn.us 651•296-6300 • 800•657•3864 • 1"TY 651•282•5332 or B00•857•3864 • AvBildble in dlFema[ive formats\ <br /> wq•wwlsts4-31 • 3/16/11 PQgP r°f� � <br />