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64/27/2016 21:26 7634975611 SPTESTINGINC PAGE 04/09
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<br /> M��.�esota �o��ut�on � Compliance Inspection Formi
<br /> Caiitrol Ag�ncy �������9 gubsurFace Sewage Treafiment Systems (SSTSy
<br /> 57C7 I.��ayNlte Road North •
<br /> St.Faul,MN 55taS-R194 I,�oc TypA;Campllance end Enio�emon�
<br /> Instructions o� page 7j
<br /> SUItltYwa�'y �OtIT7 (Cvmplet�d form must be submitted lo tl�e lacal unit of governmenl withln 1 S days.)
<br /> P�rcel iiumb��; , � �
<br /> Syslem status: ~� � ��For Locel Tracking Pumoses;�� � ��`j
<br /> � Complient [I Noncom�lianl
<br /> (based on�11 Comp118nCe requirements) ' • ' �I
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<br /> Properfiy Information N� � � �+, ~ � �
<br /> Pronerty bwner namo(s): $� N���� Prpperty owner phone: 1,�4��7'�-39�
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<br /> Prop�rty 2ddress: _,.��n�1L1iLRF!V��.�i"'�L�.'�-�Q��,4s2—, r... ,
<br /> f'roperty owner eddress(�f dlHprent); ;'
<br /> County:�.��P1.� permitting autho�ty: . D'��D�10 -•~ . .�`�.��
<br /> Date syslem conslructed: J 9 ^�S _ Reason for Inspectlon:��7����(�,f�,�,t,���� ;
<br /> System Description � . i�
<br /> Brisf syslem description: �J 170f7,,,�,� 5�vP�1�.�/��������„py� . l u�x s c lg.��_ _I
<br /> �eSaA
<br /> Lac�l permil number: � _ _ Number oF bedrooms: �__ Deslgn qw rAte: �( �O ,
<br /> Is the system: � • � '
<br /> In Shoreland�rea7 ❑ Yos � No In Weilliead f�rotecUon Area? ❑Yes � No
<br /> �An U.S. Cnvlronmenlal ProtEclio� System serving a MlnnesQfa AepartmenL
<br /> Agency(EPAj Class V Injection Well7�Yes � No oF I•leolh(MDH)licensed f�cility7 ' ❑Yes � No .
<br /> ComP�ldllCe StatU5 (Based nn sf�le r'equir�m'enta-eddiiipr�Al local requ;remer�ts may also apply.) �
<br /> Basod on llie Information galhered and repo�ted on att�cl�ed Forms,lhe compllance skatus of thls system is(check�ne): ,
<br /> �Cartifcate oF Com�liance-valid unt�l(3 years from date of reporO: �
<br /> ❑ Notice of Noncompli�nce-For Noncompllanl systoms: '
<br /> The reason for noncompfiance Is': �
<br /> This noncompllant system I5 classified a� (check one bolow): � �`^' '
<br /> ❑ Imminenl threet lo publlC he2lth a safety ❑Failinc��o prot�ct c7rotirld water' ❑ Nol in�ompliance with operFdng�ermit �
<br /> Certification �
<br /> I heraby cerlify chat a!►ihe necessary'informaUon has been,qafhered to de�ermine the complianae ataltrs of this system. No �
<br /> ' determir►allon of futuro sys(em performance l�as Geen nor cen be made due to unlcnown condifions during sysiem cons�ructlon, �
<br /> possiGle abuse of Ih�system, inadequate ma/ntensnce, or future wafe�uss,qa.
<br /> Name; ��/�r�.y �3,S�,N�¢}^�¢� Cerlificatlon number� ��rl ,
<br /> Eiusiness license name and number: S:-4' "�'�jy��, �N� �,�/,;, �' ��03-y��35fmL�or
<br /> Name of local unll of govemment:
<br /> -et7�`-~� ^ ,.�_,._ • ,� . ..� i
<br /> Signah.ire: 7. ���-- � . Q�te: 4�l�/-.��5�,,.
<br /> Required Attachments � ;
<br /> � liydraulic Performance �Tank Integrity � [� Operating Permlt Form (if applicable)
<br /> 5011 Borin� Logs Soil Separation .
<br /> System drawing/As-built drawlhg ❑Any local requirements that are different from what is required on this fo�m i
<br /> ❑Other Information(Ilst):_ _ � • •
<br /> Upgrad�Requlrements (det/ved liom Minn. Sfat. § 115.55)An Imminent threa�fo publlc 1�ealfh and safi�fy(ITPHS)musf be upgr2ded, p
<br /> replaced,or!t�„se discontinu�d w!lhln lan mon►hs of racalp!of this nollce ar withln�sliorter perlad!f requlred by lacal ordinence.If the syslem Is
<br /> falling la��otocf ground we�r,r,the syslem mus!'be upgrsded,replaced,o'r lls use disconUnued wRhln tha•Ilme requlryd by laca/ordlnan�./f an
<br /> exlsling system Is nol fplllr►g es deflned ln law,andi�as at least twe fi:ef of daal�n soll sopare�ion, then lhe sysf�m need not be upgraded,repelred,
<br /> replA�ed, or ll�use dfscontlnued,nofwllhslanding�ny local ordlnanoe thaf�a more sfrlct. Th�s provlslon does no!appty!o sysf�ms In sh��enri
<br /> arees, Wgllhead Profect►on Aroas,or flipse Used in connestlon with fopd,beverage,ah�l ladging esfeblishmenis as defined In law.
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