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12/1612008 22:46 7634975611 SPTESTINGINC PAGE 04113
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<br /> • :;.�����:��• �Minneso�ta Pollution �Om���C�nCG-�' II�SpeC��I n FQr�
<br /> ,x:�,�r
<br /> "��'' Con�rol �,gency, � �
<br />. S20 Lafayect�Raad North �xistqng Subsurtace Sewage Traatenent Sy erns (SS7S)
<br /> St P��al,MN 5�155-4194
<br /> , InsC ctlons on page 7 �
<br /> Parcel number. � � _ For Loc�l Tracking P tposea:
<br /> 3yst�m stetus: �Cqmpllant �❑ f�oncompUant �~
<br /> (based on ell compllanc�rtsqulrer�ents)
<br /> Summa�y Fanm �
<br /> Properfiy Informa!�ion �
<br /> Properiy owner name(s): � �j� � 1�1L�� ������
<br /> Property�ddress: �3► 5 S��iS•{�w,�.l�`�jp,� .
<br /> —,—�---�0
<br /> P�operty owners addness pf dlfFerent):
<br /> County:�f�.��� p'rop�rty owner phone: g �,. .-O '� Permit�ng authority: 1, � �
<br /> Date system construcNed: �9�i'7-o�� Reason forinspecNen: ,�. .;.���� ,
<br /> System Descr�ptic�n p�ayc��,,,,,�,,s,,� �,���,,,�
<br /> �
<br /> Brief system descnptiqn: 5��, �,j��� oo _ ������;.���,�,,� a ,���.��,,, ._.py, �
<br /> Local permlt number. � � ' Number of bedrooms: � Des(gn flow rate: p
<br /> la tihe system: �
<br /> In Shnreiand area? �Yes C� No In Wel(head prot�ction Area? �] es �Na
<br /> An U.S. Envlronmer�sl Protcctlon System setving a Minnesota peperlment �
<br /> Agency(EPA)Class'V Injection Well?0 Yes �No of Heath(MOH)(icensed feciliiy7 ❑�es {�No
<br /> Complianee Statu�(Based on state requiremerns,additional I�al�equirements Inay also apply,)
<br /> Bssed on the informatlon gathered and repoMed on attached forms,the compliance status of this�sys#om is(che oney:
<br /> �Certificate of Comp�iance--;ualld until(3 yeers lfrom date of report):
<br /> []N�ifce of Noncompl�ance-For Na�compiiant systems:
<br /> The reason for n ncvinpliance is:
<br /> This nonaampil�nt system Is classified as(check one below); "
<br /> [I Imrt�inent thre�t to public health&safety ❑ Falling to protect ground water I� Not in compliance with op@rating permit
<br /> Cel'ttifiCat1011(Camp�eted form must be submitted to the local unit of government within 15 deys.)
<br /> 1 hereby certify thet all elte necessary lnformetlon has been gathered to detarmine the compll�nce status af thrs s tem, No
<br /> d�terminaliort of future 4system�perfa►mance 1�es ba�n�or can be made due to unknown conditinns dur�ng systv construc(ion,
<br /> pvsslble abu�e of the s�stem,fnedequa(e me/nt�ensnce,or�ture wei`er usage.
<br /> Name: _ �V �'��,����c� Certificatlon number. _. _(�,;t,�'
<br /> Business license name and number: �-���,�,,_�►L� �,�.�,c����,�,, ,� pr
<br /> Name cf locsl unit of mment: �
<br /> Slgnature: ' ' � ,,,�_ ~`' T-- Yµ
<br /> — - ,.,`. _� Date: Z. -a�.
<br /> Required A��achm�nts Inspector Complete:This Inspectian Raport is pages long,
<br /> CheCk complldl�ae fo�9 6itt8chad: �Hydroullc PerFormance �tank fnt�grity �.3011 Sepa�ation �Operating Pe Ik Fortn(if
<br /> appilcsble) �'System rawing/As-builk drawing ❑An asses�ment of any loaal requlremenb that are cJlf6erent trom wha!18 uired on this
<br /> form �Soil Boring l,o�s ❑Ab9ndonmeM form(iF approprlate) [��ther InFprnlatbn(Ilst): �
<br /> U pgradR Requirem nfs(derived trom Mlnn. 8fat.§116.B5J An lmrnlnen!threaf fo pubNc hea/fh and axled ryTpHS)must be upg ed,reWleced,or �
<br /> • ns use d/�conrynuetl wlMlnilen monN,$of rece/pf o�thla�apaP or wOfun e sharfer padod Brequlrod by bcpl ordlnance.II flfo system!a!eqlnp to prolec!pnwnd
<br /> water,fde ayaferri musf b�up�7rad�d�eplebnd,pf(W t/se dlscOnbllllAtl YWIh/n�O NMA flequl�ed by�OC91 o1dM61/1Ce.l/'Bn exISNlfg y�9fBm is nOf l�,g aa uenney In
<br /> law,And nas et�a�((wo f of do��gn sad separaGon,thon fne sy�tem need not be upereded,,np�/roo��epl�cad or 1ts uae dlsconunued,n st�nding any
<br /> lote/ord/nenGc Flfet fs ma sfrJct rhte p►pWSlplr tloes nof ep�ly Ep sys(er►Is In SNore/eqd�s,WaNhelld Profeqloq qroas,wfhoae rn'd M neeHnn w1U�/ood,
<br /> beverligo,and/od9Mg osf idsfllntnN3 e9 deqi�ed!n leW. "
<br /> wq•wwists4-31 I Com Uance Ins ctlon Farm o Facist�n SSTS
<br /> ai�/oa . P� Pe � � �
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