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_.__ <br /> � <br /> , , , <br /> , ,, . , ' <br /> � Minnesota Pollution ' - <br /> ��� ControlAgency �0 l�ance inspect�on Forrt� <br /> ����_` . P <br /> . 520 Lafayette Road North Existing Subs( rtace Sewage Treatment Systems (SSTS) <br /> St Paul,MN 55155-4194 r <br /> iInstructions on pa�e 7 <br /> Parcel number: <br /> System status: - � For Local Tracking Purposes: <br /> ❑Compliant �Noncompliant j <br /> (based on ali compliance requinements) ` <br /> Summary Form <br /> Property Information <br /> Property owner name(s): �i L� <br /> Properly address: S p L,L�. �,� <br /> Property owner's address(if different): <br /> Caunty:�l� r�l!.� Property ow�er phone:°► � � � �. __ Permitang autho�ity: _�¢.p�� <br /> date system constructed: j aj�� � Reason for inspeotion: <br /> System Description <br /> Brief system description: � <br /> Local permit number: ''3 l S�� Number of bedr Q��s: ___�___ pesign flow rate: __ (o d v <br /> Is the system: 1 <br /> In Shoreland area? �Yes ❑No In Welihead Protection Area? <br /> An U.S.Environmental Protection ❑Yes �No <br /> Syste� serving a Minnesota De artment <br /> Agency(EPA)Class V Injedion WeU?�Yes �No of He�th(MDH)licensed facility? ❑Yes �No <br /> COI71PI11f1Ce StdtUS(Based on sta.te requirements—additional I� 1 requirements may also apply.) <br /> Based on the information gathered and reported on attach�fonns,the compliance status of this system is(chedc one): <br /> ❑Certifiqte of Compliance—valid untii(3 years fivm date of►epo ): <br /> �Notice of Noncompliance-For Noncomptiant systems: <br /> The reason for noncompliance is: � <br /> This noncompliant system is ciassifled as(check one bel ); <br /> ❑ Imminent threat to pubiic health 8 safery �Failing to pro ect ground water <br /> . []Not in compliance with operating permit <br /> Cei't1flCatlOtl(Completed form must be submitted to the local uni of govemment within 15 days.} <br /> l her�sby certify thaf all the necessary inf�rmation has been gathe to deteimine the comptiance status of this system.No <br /> defe�mination of future system performance has been nor can be m de due to unknown conditions during system construction, <br /> possib/e abuse of the system,inadequate maintenance, or future w ter usage. <br /> Name: �����. � ��, <br /> �.'Qr��S � Certification number. _ (d�� <br /> Business license name and number: _$ —t-��-fj, L� � '��c� � 3..�c27� �'�C or <br /> Name of local unit of govemment: <br /> Stgnature: .��� �„ �J. � <br /> Date: '�--,� � --p� <br /> Required Attachments Inspector Co piete:This Inspection Report is pages long. <br /> Check compliance forms attached: �Hydrauiic Perfortnance ❑T nk Integrity �Soil Se aration <br /> applicable) �Syetem drawing/As=buiit drawing (]q�f��g�e�{of a y Iocai requirements th t are d�ftom whaP s requ red on this <br /> form �Soil Boring Logs ❑Abandonment form(if appropriate) ❑Oth r informatlon(list): <br /> Upgrade Requirements(de►fired from Mfnn.Stst§115.55)An Lnmk��►,t threar to puWic hea�n and sarety p7pHs),m,st pe upgreded,,ep�aced,or <br /> !!s use dlscrontlnued wltlMn ten montl►s W recefpt o/thfs notice or w/thJn a shaterP�d if iequJred by local adfnance.N the system Is fe3�ng to protect ground <br /> waler,the system must 6e upgraded,�eplaced,or Ns use disconUnued within/he Um requbed by focal o�n� !f an exisqn <br /> law,and has at/east t►tiro feet of deslgn sor7 separatlon.yip.n U�e system need not u 9�em is not IaUing as defined in <br /> locaf ord/nanar Urat ls more aU1ct.Thls ������M�ed,or fJ8 use d►gppnUnue�nphpkhsta�i <br /> Frovision does»Df 6/iply to sysfems!n nd�ess.WeBhead Piotection Ateas,or lhose used In oonnecNon.�'v,m n� <br /> beverege,and lodging estabNshments as del�ed/n/aw. <br /> wq-wwists4-31 <br /> 4/f/o8 I Compliance Inspection Form for Existin�SSTS <br /> I <br />