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'`'���,,,es°t� P°���t�o�, Compliance Inspection Form
<br /> Control Agency
<br /> Existing Subsurface Sewage Treatment Systems (SSTS)
<br /> 520 Lafayette Road fVorth
<br /> St.Paul,MN 55155-4194 Doc T}�pe Compliance and Enforcement
<br /> Instructions on page 7
<br /> Summary Form (Compieied form must be submitted lo tfie local unit of government within 15 days.)
<br /> Parcel number.
<br /> System status: ❑ Compliant � Noncompliant � For Local Tracking Purposes: ;
<br /> (based on ali compliance requiremenls) I ;
<br /> L.—, I
<br /> Property Information - — — --
<br /> Property owner name(s): _ p y p � ti Z� �, 4�?- �'�(frJ
<br /> -�p"4� `� ����L__L0�;1a'�?�'�l �`r..:. Pro ert owner hone: � �
<br /> Property address: ���fip ������� L����
<br /> 'P vY}_,�_�___��:-�ZS�.:)
<br /> Property owner address (if di(terent): --
<br /> County: �-��: ,t�.`�c,,��31 Permittingauthority: __��.5,.( p�: ����n
<br /> Date system constructed: �9��;�j Reason for inspection: q'%�qT�'�Y;�:-;.�j 1�2:�,k���{;"�r'_
<br /> System Description
<br /> Brief syslem description: _d-loDp �p 1 SfC-'P�1C -(f�>.��F-S � -/uU�Uo�t� �(�Z��.1��_����
<br /> Local permit number: _ Number of bedrooms: _l�__ Design flow rate: (oU 0
<br /> is the system:
<br /> In Shoreland area? � Yes ❑ No In Wellhead Protection Area? ❑ Yes jQj No
<br /> An U.S. Environmenlal Protection System serving a Minnesota Department
<br /> Agency(EPA)Class V Injection Well?❑ Yes � No of Heath (MDH)licensed facility? ❑ Yes
<br /> �i N o
<br /> COfT1P�idllCe $tatUS (Based on stafe requiremenls-additional local requirements may also apply.)
<br /> E3ased on the information gathered and reporled on attached forms, ihe compliance status o(this system is(check one):
<br /> ❑ Certificate of Compliance-valid until (3 years from dale of report):
<br /> � Notice of Noncompiiance- For Noncompliant systems:
<br /> The reason for noncompliance is� �1�y�.�-.---�_�.,.��o �
<br /> Z�1� �',',�1'-�Oc�>'���,� 4��1�F^a ��o1LS�
<br /> This noncompliant system is classified as (check one below): —
<br /> ❑ Imminent threat to public health & safety � Failing to protect ground water ❑ Nol in compliance with operating permit
<br /> Certification
<br /> 1 hereby ceriify Ihat al!the necessary information has been gathered fo determine the compliance status o/(his system. No
<br /> de�ermination of future system performance has been nor can be made due to unknown conditions during system construclion,
<br /> possible abuse of the system, inadequate maintenance, or future water usage.
<br /> Name: Gi ��.�__�, SLN���,�.��c,, Certification number: (o a,�
<br /> Business license name and number: �-Q �('��1�� ��G L�L. � �9 W- �e3 -y��-35i�to o�
<br /> Name of local unit of government: ;,,
<br /> Signature: l�---- '', �-�__-__ -- -- Date: �j �11�P'Y
<br /> Required Attachments
<br /> ❑ Hydraulic Performance ❑ Tank Integrity
<br /> �`" 9 9 � Soil Separation ❑ Operating Permit Form (if applicable)
<br /> Soil Borin Lo s
<br /> � System drawing/As-built drawing ❑ Any local requirements that are different from what is required on this form
<br /> � Olher information(list): ���,���/ �,j-�'�f, ,��
<br /> Upgrade Requirements (derived from Minn. S(at. § 1 i5.55)An imminent threat to public health and sa/ely(ITPHS)must be upgraded,
<br /> replaced, or its use drscontinued within fen months ol receipt of thrs notice or within a shorter period il required by local ordinance. !f tl�e system is
<br /> lailing fo protec!ground water, the syslem must be upgraded, replaced, or its use discontinued within fhe time required by local ordinance. Il an
<br /> exisling system is not lailing as defrned in law, and has af least two feet of design soil separation, lhen the system need nol be upgraded,repaired,
<br /> replaced, or ifs use discontinued, notwithsfanding any local ordinance that is more strict. This provision does not apply to systems in shoreland
<br /> areas, Wellliead Profection Areas,or fhose used in connection with(ood,beverage, and lodging establishments as defined in law
<br /> www.pca.state.mn.�s • 651-296-6300 • 800-657-3864 • TTY 651•2B2-5332 or 800-657-3864 • Available in alternative formats
<br /> wq-wwists4-31 • 4110109
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