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OCT. 22, 2009 2; 27PM Edina Realty Wayzata-RR3 N0. 3565 P. 2 f , r Minne�otapollution Compliance Inspection Form Contrc I Agency SZOl.afaystteRoadNorth Existing Subsurface Sewage Treatment Systems (SSTS) Sc.Paul,N N 55155-4194 Instruttions on page ; Parcel number: � �, Fo�Loca1 Track�ng Purposes System siatus: Complianl ❑Noncompliant � (based on all com�Ince neqvlrements) � �,: r Summary Forim �- Property Inforrnation Property owner na�ne(s): � S ._, _„_ . Property eddress: � YV�L�h 7� Property owner's�ddress(if different): COUn � � y:�vt; Q,V� Property owner phone:�I�-�5`�' �0 a� Permitting authority: c( �'�l� (a�p�� ...._ t �, T Date system consl�ucted: � O Reason for inspection: ____ SG�Il� ,.___._. .. . System De�criFtion Brief system descr�ption: ` �C � �_ S4�'C� J .. Local Dsrmil numb 3r: Number o bedrooms: Oesign flow rate: _(B �.. . Is the system: In Shoreland ar�a? ❑Yes �No In Wellhead Protection Area? ❑ Yes I�No An U,S. Environ nental Protecdon System serving a Minnesota Department Agancy(EPA)C ass V lnjection Well?�Yes �No of Fieath(MDH)licensed facility? ❑ Yes �No COI'11PI1d�Ce $ti tUS(Based on state requirements-addltional loca)requirement� may also apply.) Based on the infonnation gatherad and reported on attached forms,the compliance status of this system is(ch�ck one� �ertiflcate of Ci�mpliance-valid until(3 years from date of report): ______._. ❑ Notice of Noncc mpliance-For Noncompiianl systems: The reason f��r noncompliance is: ____,,,.. _ _ This noncorripliant system Is classifled as(check one below): ❑ Imminenl :hreat to public health&saFety �] Failing to protect ground wecer ❑ NOt in Compli�nCe wiih operating parT� �e�1f1Cat1Dt1 (C��mpla�ed form must be submitted to the Iccal unit of government withln 15 deys.) I hereby'ceriify��lTa sU�he ne�essary informBNOn heS b6en g�thervd lo defermine the ComplianCe status of th�s system Nc determ,narion ol!u u�e system perfoimance has been nor can be mado dus to unknown conditions during sysrem consrruci,c�• possible abuse o/!1e system,inadequ te maintenance, or future water usage. �y Name: _.�,1� Certification number: ��"l._._... Business license name and numbe�: �y� �1�Uj�Q,s �,�,L �5 �"„ , or Name of local uni ��ovgrn ent: .__. ._ . Signature: Date: ��,�q. , . _ Required A tacnments �nspo�to�comp�e�e:This Inspection Report is � pages long. Chack complia ci�forms attached: L�iydraulic Pertormance �'ank Integ�ry H Soil Separation 0 Operaung Pertn��Form��i appl�csble) y�tem drawinq/As-built Orowing p An assessment of any local requirerr�nts that are d1f(ereni�rom wha��s rea��rea on;r�s fortn �Soi Borir p�ogs ❑Abandonment fortn(If approprlate) ❑Oiher I�fortnat�on(ibt): Upgrade Requl rements(dedved!rom Minn.SfaL§11�55)An imminent Uaear�o oub�lc hes��h and aale�y(IrPHS/musi be uPq�aaeo��e�acec � i!r use diseonUnusd�ifAiA Isn moAlhs of roCei01 ollhit nodC•o�Yw'fAin s shoAar period il/aquir�d Ey loca/ordinance.1!fhe ayalam�a lau�ng w Oro�ec�y�a��: waler,Iha syslerrr m��s�W upyraWO,npbC�O 0�Ns vse O�stonf�nuod WdAin lha Urn�ropuirod 6y locaf o/dinanca.llan axisGng sy�iem�s noc lar.r.g 33 ee��r: ^ �aN,and has a(leasl fwo lesf o/dsaipn ao�stpsnlion,fAsn(llo syslom nead nol ba upgraded,rep�ired,rep/aced,wira use O�sconunued no(w.t^i'b%':�:;�^, local oidinance(haf�s moro sf/icL nris proviaion doos nol apply 10 syslems in ahaaland areas,We!/Aead Piolec�ion Areas,oi l�ose use0'i��C0�'1!l"�"�'�'::: oere�age,and lodpir g eafabliahmenls aa defined�n law. ..-.-. ,. �----"---- �.._.._ . � . � .._.