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01/31/2612 14:31 9528733112 PAGE 02/66 . 4 , Minnesota Pollution Compliance Inspection Form Control Agency 5201afayetteRoadNorth Existing SubsurFace Sewage-�Treatment Systems (SSTS) St.Paul,MN 55155-419� InstruCkionS on page , ParCel number: For Local Tracking Purppses System status: Compllan� � Noncampliant (based on al1 co pliance requlrements) Summary Forrn Property Information �t�. Property owner name(sy: ' `1 ��J �� .__.__. ...---..- ...� Propeny address: �� •--- • -•• -- Propefty�'s address(If different); —_.._..____ ..•• County n j�� Property owner phone: Permitting authority: __„�,. ,._,,, , Oate system constru�d� Reason for inspectlon: _ ___._.., .__.... System Description �?�l� ' i s stem descri tivn; � G � _ T � .��/�T/ ( Bne y p _ - /�� Local peRnii number: _ Number o(bedrooms; _� esign flow rate: _.C.�/�-`r Is the sy5tem_ In Shoreland area? �'1Ses ❑ No In Wellhead Protection Area? ❑Yes No An U,S. Environmental Protection System serving a Minnesota Department Agency (EPA) Class V Injection Wefl?�Yes �'�- of Heath (MDH) licensed facility? ❑ Yes : o COt11PI1df1Ce Std'�US(Based on state requirements-add�tional local requirements may also apply,) Based on the information gathered and reported on attached forms,the compliance status of thls system is(check one� �ertificate of Compllance-valid until(3 years(rom date of report)� _ __ ________.._ ❑ Nolice of Noncomptiance- For Noncompliant systems: ' The reason for noncompllance is: _.-••-•-•-•••• -• -•- This noncomplfant system is classl�ed as (check one below); Q Imm�nent threal to publlc health �safety ❑ Failing to protect ground water ❑ Not in compliance witn o{�era��ng perm�' Ce�tlflCdtlO� (Comp(eted form must be suDmltted to the(ocal unit of government within 15 days,) 1 hereby certily that all fhe necessary information has been gathe�ed to defermir,e fhe compliance status of In�s sysren� �ve determination ol future system per�ormance has been nor can be made due to unknown conditions during sysrem cor,sir��cr.o�� possible abuse o(the Sysfem,inBd6qu te mainfenanCe, or future wafer usage. Name' ,,,��_��1�� _ ___ Ce�flffCation number; ��-l_.__ eus�ness license name and number, __ �IC�..S �nL �a�.�__, . _.. _ or Name of local u � over nt; —. -- --•-• - � Signature; Date: __�.� - �--- - - Required ttachments inspec�or comp�o�e;This Inspectlon Report is �pages long. Check compl' ce forms attached:�ydraulic Pertormanc�lTank Integrl�y [�I Separatlon 0 Operating PeRn��Form��I applicable stem drawln As•built Orawing ❑An a55855i�enl of any lo�al requir6menls that are Oifferenl from what�s requ�rFd on �•;;,s form ❑ S Bon g Logs ❑Abandonment form(if gpprop�ate) ❑01her informetion(Ihst)� Upgrade Requiremants (derived Irom l��nn. Sfat.§ ?15,53)Anlmminent lhreaf lo DubNc hea/fh end aalety(f7PMSJ mvsf De upgradeo,repiacec : ies use tliSGOndnued wi�hln len moAfAs olroCeJpt ollAis nolice oI wi1hM e snoRer period�f�eqvi�eo by Jncal ordlnanre.!�fAc syslem is la�6ng�a oioiecr�ro��: waler,Ihe sys/em musl be uppra0ed,ro0leeed,or ifs use GiSCOnNnuad wilhln Ihe lime�o0u��o0Oy loca!orOrn6nce.!f ar1 exisllnp sys�em�s nor/awng as ce`�e.- �• �aw.and�ss el leasl�wo�e610�d�sipn soll separal+0�,f��n Ine syslem need nol be uD9�Aoea,iepelred, repleced,o��Is use O�scon��nuea.norrv�:�s:3-�c�;.:s-, loca�ordina�te 1�8f is more strlcl. This Oro��sJon ooes nol apply Io sysrems in snarelend a�eas,wellneao P�olection Areas,0/MOSP uSfd��;on.�r:�,.;,^,��:�•_:_ oe�erapo. ��d/odgmg eslablishmenls rs QeAned in law. .. � r��ii....�., i.....,.�.:..., c...._. r.., c_,..�..., c:'r: