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e3/22/2011 22:49 7634975011 SPTESTINGINC PAGE 03109
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<br /> ,, ; ,� Minnesot�i F�olltation Coimpliance �n�pect�o� F'�orm '
<br /> �' , � �`' Control Ac�ency
<br /> `�'>���, Eyrps�ing Sub�urface Sev�aage 4re�#tt�en� �ysferx�s (331r3)
<br /> 520 I_aFayelc�Road North poc Typo:Compliance And Enforvement
<br /> St.Pnul,MN 55155-�79�1
<br /> I�structions on pag��6
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<br /> SUm1'1'�iyY'� FOI'1�7 (Completed form must be submi�ted to the local unit of governmQnt within 15 days.)
<br /> Parcel number_ .,., ....,� _ .,._._ _,...,_,_-r-------.�...._� �
<br /> ' For Local Tracking Purpases:
<br /> System status: �Compli�nt ❑ Noncompliant
<br /> (besed on all Gomplfance requirements) ,
<br /> ,.w ------- ----�� ...,, -i
<br /> Pro�e�t,y Informa�ian �
<br /> P�openy owner name(s): ,.�� '9 -.,\�1„_,__l-�Ol.�.1�l�� „___ Property ou►ner phone: �SZ^4�a�•q ao� I
<br /> Propecty address: c��5.�.�'D_���=�...'\_�(!Wl'_1.�...�0�0_15�..,..---- __._..,......___._---...:_...�-�
<br /> ----... ...
<br /> I'roporty owner eddress(If difFF�rsnt): __,_.__ ...,.�- ----•----.— ........__ __.._.__ .,..�_�..--I
<br /> Permiiting authority� GI�'!�.,._,0.�!,._�J��Q_..,.-- -- ----
<br /> Gount,y'—�_'�_r,1.�.�,��?9^� ,.. �
<br /> DatR system constructed: �-���0►� __„__ Reason for In&poction T�Q�'��f'Q%�jJ��— ---
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<br /> System IDescription ���,�,� a�p,�,��,,� �
<br /> Brief sys4am description: �.a�a.�J��1..�.�G�i�-���.�a�'�ar��4►����.NS.o►��,,Ll��1.5�..�kQQ^�.
<br /> Lacal permit number. .._. ,,....__ Number of bedrooms: _____,5 Deslgn flvw reto: 7 �c�,�����,_,�__.__ '
<br /> �s erie svstc�m: �
<br /> I� Shoreland ares? �]Yes �No In�lellhead Protection Area7 � �]Yes � Na
<br /> An U.�, �.:nvironmental Prol2ction Systom sen►ing a Minnesota Depe�rtmvnt
<br /> Agency(I�PA)Class V In�eotlon V11ell?[]Yes � No of I-leath(MDH)licensed facillty? []Yes �No j
<br /> COI'i1�JI17f1�Ce $$8t11S(9asecl on stats reqUlr�menfs-edditional local rsquirements may also epply.) �
<br /> Based on the information gathered and reporled on attached forms,the compllance status of this system Is(checic one):
<br /> � Cartificate of Compllance-velld until (3 yoa�s�m del�e of►epo►tJ: �,__ ______,_ �
<br /> [�Notico of Noncompliance-For Noncompliant systems:
<br /> The reason for n�nr,ompliance is: _�_,.,,..,......�,_.,,......_,r- — .,,_....•.,-- _.,.._-,..._,_�I
<br /> This noncom�liant systelte 65 cl�ssi�iecl as(check vne below): '
<br /> �] Imminent threat to p�abllc health 8� safeky [� Failing to protect ground water ❑ Not in compliance with operating permit I
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<br /> Cer�9fic��tion
<br /> 1 hore6y certify that all!he necessary infnrrneNoi��l�es been gatherod to defeRnfne tfie complianr,�status c�F thPs sys��em. Nv
<br /> detormination of futur�syst�em perforin���ce has peen nor can be made duQ to unknown conditlons du�ng system consfrur,tion, ,
<br /> passible abuse of the sysitem,Inedequatta m�int�+nance, or future weter usacio. �
<br /> � � � Certification number� �,�'','�,
<br /> N�me: --.����/'��, ,.r.7. ��.���:�'_I�i'4y.��a • �_�.:..•_,�^--------,aJ_
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<br /> 13uslnwss Ilconse namo and number. S�'4 °t'�(sS��l�-J>> 1�`„�,___.,.�.,1.L' �„b�...���'_� 't'�1'�' `1 l,o`j��4`1_rl=',�irin�a ar !
<br /> Namo of local unit of government: ,,._ .............._._._,.._,r..._ --.-.--.-:,---..,......,__.
<br /> Signature: U'�� .ti--��"',,.,...-------- D�te: .. 3-17 ��vt�
<br /> �...... .,.- � _.....
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<br /> Required Attachrr�ents
<br /> � Hydreulic Performance � Tanlc Integrity ❑ Op�rating Permit Form (if appllceble) j
<br /> � Soil Boring Logs � �ail Separatfon �
<br /> � System drawing/As-bufl�d�awing ❑ Any local requirements that are difFerent from�n►hat is r�equired on this form ;
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<br /> ❑ Other In9brmotlon(list): � --�---�--�- �
<br /> Upgrade t�eqUirements (derived from Minn. Stet. § i 15.55)An Imm�nent thr�At to puhllc heAl�h end saPofy(ITPHS)must be upgradad,
<br /> r�eplaced,orits use dlscontli�uod within ten monfhs of receipt of th(s notice or withln e ahorler peNod 1I rmqulred by local o►rJindnr,e, lf the system Is
<br /> falling to proteci ground watar,fha systom must b�Upgraded,replaced,or lls use discontlnued within the llms roqulrrid by/oca!ardinance.IP ar�
<br /> existing sysiem is not falling as deflried in law,and has aG leest two feet of dosign soU separaf(on, then the system neatl no�be upgr�dod,repei��ed,
<br /> replr�ced, or Ifs use dlscontinuQd,notwitHatending any IocAl ordinAnce Btet is morr3 qtrlct. Thls provlslon doas not epply to aystr�ma In shoreland
<br /> areas, Wellllesd Proler,llon Ar�as, or tl�ase used!n connectlon wlth food, beverege,and lodgln�►estebllshmenls as dQfinod in law.
<br /> _ .._�_.......,.,�:_,._,. __._,_,....._...:.,,_......_,....__ ,.,._
<br /> .._._ ....-- -.._.._ .._._ .._ .�. +n• �tnn nnn ie��ni� rn�Rr� �n� ����__nnn ie�►'10/J �..�il�i.l_o_ �I��w..�s.-e-_--`-
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