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06/08/2010 23:37 7634975e11 SPTESTINGINC PAGE 05113
<br /> M�nr,�sot, P���L�t�on Compliance Inspe�tion Form
<br /> Control Agenty ��;sting SubsurFace Sewage Treat�r,ent Systems (SSTS)
<br /> 5�0 Laf�yefte koad Ivvrth �
<br /> Sl.Faul,MN 55155��A194 I7oc Type�Cornplisnce and En/urcemonl
<br /> instructions on page 7
<br /> Sult1mary �oA'N11 (Completed form must be submitted fo lhe loc�l unll of govemmenl withln 15 days.)
<br /> P2�rcel numbpr;
<br /> — --,� .---. — _, - --For l,ocel Tracicing Pi.irposes: .. - -'��j
<br /> Syslem sl:aU.is: ��Compli�nl ❑ Noncompliant �
<br /> (b.ased on all complrance requirements) � I
<br /> .._ .._,,.. _ �. _,�
<br /> Property Information
<br /> Proporty ow�ier namo(s): Qg����N�G,��� __„ �_ I-''r��erty owner phono. '��'z.'4�`„�M�g c�
<br /> Prop�rty adclress: .�L�U.�k3�1?��'�'S��...._ ��Qf��;cJ —---- � -- -- - .
<br /> Property own�r acl�lress(If dlfferent); __�_ . _ _ _ _ .
<br /> County: _�,��f���� _..... Permitling authbrilY= .L..IS��J'�... �I'�J�1�__, ___ ' - -
<br /> . ... - -�--
<br /> Datc syslern construr.tecl; ___,,.. _ f�eason for inspecUon;.__�g���,,�y_ �,�.,,M � ` _
<br /> Sysfiem Descrip�:ion
<br /> • Bricf,yslem�escription; �/o�c?_..�.,( S�'�11�'�i4�l•ti��� o����ya•��_�D�J?S�.o l0,,�39�`�_L�yp,
<br /> ....._ – _d,_. �
<br /> L,qr..al permil number: _,_,, Number of bedrooms; 3 Design ilow rate; _�1�,_____
<br /> Is the system; ' �
<br /> In Shoreland ar�a? � Yes ❑ No In Wellhead f�r�kectlon�roa? ❑ Yes � No
<br /> An U,S. Enviranmental Proteclion System serving a Mfnnesota Deparlment
<br /> Agenr,y(CPA)Cl�ss V Inje�tion Well7 Q Yes �No of I-Ipalh (MDH)lir,ensed Faaility? ' ❑ Yes � Na
<br /> CoRlplianCe StatUs (�3ased on stala requirerrients-��addil/onallocal►�epuiremonls may a/sn�pp/y.)
<br /> Besed on the information c�athered and reporfed on attachecl forms, U�e compliance status of this sysiem is(r,hed<nn�); •
<br /> � Ccrtificate of Compliance–valid until (3 yefl�s from d21e �f ropo►�J: ____., ___,
<br /> ❑ Nulice of Noncomplianc�- For Noncom�liant system�: �
<br /> The rea�on for noncon,plianr,e Is: ____� . _
<br /> This noncompllant system Is classified as(check ono below); 1 �
<br /> ❑ Imminenl threat lo public haalth 8�seFety ❑ �alllnh to protc�c!c�rourid water ❑ Nol in compllar►ce wilh onerating permit
<br /> Certifiication
<br /> 1 hereby cartify rhaf a!1 the necessary lnformali�n has been qalhe�'ed fo defermine Ihe eomplianc9 qtatus of this sysfem. No
<br /> determ/nation of f�lture system performance l�as boen nor can bo made due to unlcnawn conditions during system conslruction,
<br /> posslble abusc of!he system, inadequale meintcn�nce, or(uture wale�usPge.
<br /> N�me: �f�h/����SGN��?�Z���S, ..__, Cerlificatlon number: �_�j_a�1
<br /> C�uslness lir,ense neme and number: 5=4 ''�����.p,��,�_��, ., _ ��L,.,�° �,�y� '1 b�.,��9�-35�,or ^
<br /> NamF of locel unl of g�ver ent-
<br /> Slgnature: � �.��J`~•-,-�'�"`,, _ ..,.. ,.._..._ . �_. Datc: ..___�8..�. ,.i ���_..., . `
<br /> Required ,4t�achments
<br /> � Hydraulic Performance �Tank Intogrity ❑ Operating Permlt f orm (if applir,eble)
<br /> Soit Boring I_ogs ��Soil 5o�aration �
<br /> �Systwm drawinglAs-huilt drawing ❑Any local roquirements that are dlffcrent from whal Is r�quirecl on thfs form
<br /> � Othe�Ininrmation(Ilst); ���V'��g9 Q�.�G ✓�� �
<br /> �=-,...,.. .. ,._�. ._ _ , „
<br /> Upgrade Roquirements (derived from Mlnn. Srat. § 915,55) An imminent fl�roaf to publlc heal(h and sa�efy(ITPI-IS)mustbe upgrad�d,
<br /> replaced,c,r!Is use disconUnued wlthin rpn montl�s o/receipt of thls notice or wltliln a sHorter perfod if requirtd by local oroinence, !flhe sysfem/s
<br /> fnll/ng fo protPr,f pround waler, U»sysfern mus�be upgradad, ropleced, o�i�s use dlscondnued wlthln fl�o�llme reqr,lred by loce►ordlnance. /f an
<br /> exlsting sysfem Is naf falling as de/)nod In law,and h2s af leasl fwo fcal of design soll separAfion, (l�en the sysfem nood nof he upgradPd,rapalrod,
<br /> repleced, or Its use dlscontlnuod,nolwlthstending any locef orciinance that ls mora striCi, Thls pr�vision doos noI appl,y to systoms In shoreland
<br /> areas, Wellhead Protectlon A�pas, or those used In connoctlon wlth food,bevera8e, and lodging eslabfishmPnts as doflnad in law.
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