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07/30/2669 21:14 7634975011 SPTESTINGINC PAGE 03/09
<br /> "'�n:^es°�a p°�,�t�on � Compliance Inspection �orm
<br /> • Control ,�gency
<br /> Exist�ng Subsurface Sewage Tt�atmen# Systems (SSTS)
<br /> S�p l,afayette qoad Norch
<br /> St.Paui,MN 55155-4194 • Doc Typo:Compliance and F_nlorcerrlenl
<br /> � (nstruction� on page 7
<br /> StJ�771'�ary For111 (Completed form must be submitted to the Iocel unit oF governmenl withln 15 day�,)
<br /> P�rcel number; ,
<br /> Syslem status; �Com�lf2nt ❑ Noncomplianl . For Loce�Tr�cking PurpoSes; � —�'—•�
<br /> I
<br /> (based on a!!comp!l�nce requiremenlsJ I
<br /> , �
<br /> Property Information � `—" — �
<br /> prQpEr#y owner name(s); .�?����y j��.�,�4
<br /> �_.. . � property own�r rhone: ���ed�`���.^
<br /> Property address: �,�Q_�M�������g ,�� _ !�
<br /> Property owner�ddress(it dl�erent):�,� � �`� . �"�"��' � —
<br /> County:�����,1 Penniiting�ulhority: .�� o � . �-
<br /> Date system constructed: � �"'������ �
<br /> �n 0�_. ,_ Reason fo�Inspectlon_'���.�{ •��5,�
<br /> System Descript9on , � � .
<br /> Bri�f system description: �,"13d��� �i0��.\�r�, ,�.� .,���W� � 1��Q���, ��
<br /> `=`-"-�ra" �4 pJ �-►-�'� „
<br /> I.ocal permit number. ^ Number of bedrooms: $� Deslgn flaw rate: �S�} ��
<br /> Is the system: � ' , �—�-
<br /> in Shoreland aroa? Q Yes � No In Wellhead Protecticn Area? ❑ Yes �No
<br /> An U.S,Environmental Protection System serving a Minnesota Deparfinent
<br /> Agency(EPA)Class V InJection W�II?Q Ye9 � No of Heath(MDH)Iloensed f�cility? ' ❑Yes � No
<br /> COIT1PI1dI1Ce S�dtUS (Besed on st�fe requi'remenls-addition�l locs/roquiremer�s may also apply,J
<br /> Based on ihe informallon gelher�d and reported an att2chEd forms,lhe cornplfance status of this systam Is(checlt one):
<br /> �Certlflcat�of Compliance-valid until (3 years from datQ ofrepo►7): �
<br /> ❑Nolice oF Nvncompliance-For Noncompliant systems: T
<br /> The reason for nnncvmplianca is':
<br /> 7hls noncompliant systern is ci�ssifi�d as�heck one belouu);� � ��� "" '
<br /> ❑ Imminsnl tlir�eat ta public health 8�safery [] Faiiing to protect ground water [j Not in compliance with vperating pErmit
<br /> Certif9cafiion
<br /> I hereby cerllfy that�II the necessery'inform�flon has been gathered to�efermine lhe comp/lence slatus of this syslem. No
<br /> � determi�ation of fuh�re sysbm performance HAs been na can be made due to unknown condltlons during system consln�etion,
<br /> possi6le abuse oi the system,inadequate melntenance, ar future water usege.
<br /> Name: ����, L .���¢�¢S � Certlfication number: (a a�
<br /> . Business license name and number: �-Q������, �,,,� �!+ �
<br /> ��9�to_3-4°1�-35��or
<br /> Name of local unll of govemm�nt�
<br /> /�— ,Q .w�
<br /> Signature: :��,�1�- ...----- � Dake: �� -ac���,�. .�
<br /> ��� ��
<br /> Required Attachments
<br /> � � Hydraulic PerFormance �Tank Integrity . ❑ Operating Permit Form (If applicable)
<br /> Soil Boring Logs �Soil 5eparatlon .
<br /> �System drawing/As-buill drawing Any Ibcal requlrements that are different from what is required on thfs form
<br /> ❑Other Infiormation(Ilst): • •
<br /> UPOrad�Requirements (derived from Minn. Staf. § 115.55)�In Immthent lhrao�!o publlc heelfh and s�fely(ITPhIS)must be upgnade^d,
<br /> repl�ced,or its us�disconNnued withM Isn nronfhs ol receip�of thls nol/c�or withln a shvrler poNod!I requlrod by/acal ordinance.!f fha sysiam!s
<br /> fs111ng�o protect Arnund woler,tho sysf�in musf be upgrPded,repleced,or/ts use disconlMued wfthtn the•Nme repu/red by Mcal ordinanco. If an
<br /> exlsf/ng��ystam is nof falling os deqned In law,and fies af leasl tvw fee(of cfes/gn soll sopareHon,fhan!ho sysfam nead not be uPBrmded,repalr+ed,
<br /> replaced,or Ifs use dlscondnued,no(wqhatand►ng any bcel ordlnence fhaf Is more atMcl. Th)�provision does not epply to systems In shorelAnd
<br /> areas, WephaBd nrotecflon Areas,or those used in oonnec�ion wlih food,beverage,end lodging estabNshmenfs as defined In lew, ,
<br /> www.pca.state.mn.us � 651•29b•6300 • 800•657•3�6q . TTY 651•28Z•5332 0��00-657•3864 •� A'vailable 1n attemarivP t��mat�
<br /> Wn-wwle►cA.7i . A11RlI1R
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