Laserfiche WebLink
• <br /> Minnesota Pollution Compliance Inspection Form <br /> s Control Agency Existing Subsurface Sewage Treatment Systems <br /> 520 Lafayette Road North \ ($STS) <br /> St.Not,MN 55155-4194 • <br /> Doc Type:Compliance and Enforcement <br /> Instructions: Inspection results based on Minnesota Pollution Control Agency(MPGA) For local tracking purposes: <br /> requirements and attached forms-additional local requirements may also apply. <br /> Submit completed form to Local Unit of Government(LUG)and system owner <br /> within 15 days <br /> System Status <br /> System status on date(mmlddlyyyy): 7-a,V <br /> •Compliant—Certificate of Compliance ❑ Noncompliant—Notice of Noncompliance <br /> (Valid for 3 years kom report date,unless shorter time (See Upgrade Requirements on page 3) <br /> frame outlined in Local Ordinance.) <br /> • <br /> Reason(s)for noncompliance(check all applicable) <br /> ❑Impact on Public Health(Compliance Component #1)-Imminent threat to public health and safety <br /> ❑Other Compliance Conditions(Compliance Component#3)-imminent threat to public health and safety <br /> ❑Tank integrity(Compliance Component #2)-Failing to protect groundwater <br /> ❑Other Compliance Conditions(Compliance Component#3)-Failing to protect groundwater <br /> ❑Soil Separation(Compliance Component #4)-Faring to protect groundwater <br /> ❑Operating permlt/monitoring plan requirements(Compliance Component #5)-Noncompliant <br /> Property Information Parcel lD#or SeciTwplRange: ' i.14.100e% C 0 - • <br /> Property address: 40't..dvcx -t ; Ore O1191a U Reason for inspection:?AW' ! - t.4 - <br /> Property owner L .o�4>a Owner's phone: c1 -9'l i-• <br /> X33 S <br /> or <br /> Owner's representative: • <br /> Representative phone: <br /> Local regulatory authority: ../44-< tl - erlovs.o • Regulatory authority phone: 9 47.- as on -4 voQ <br /> Brief system description: itsas> 4""-S '0V -;a toA414AS 'VcrAVeinvo s1Mk"V %%In- <br /> Commentsmments or recommendations: 4o0v.i. 50 y 0),4 1N-3 WO? #a a .g vn steel S4 -view1 ria <br /> • <br /> • <br /> Certification <br /> I hereby certify that all the necessary information has been gathered to determine the compliance status of this system.No <br /> determination of future system performance has been nor can be made due to unknown conditions during system construction, <br /> possible.abuse of the system,inadequate maintenance,or future water usage. <br /> Inspector name: 5-f flit A..•_S C:�1�11'Prt� - Certification n number. (02,1 <br /> Business name: 5 4 - ' \, 14 t3, License number. -fly 9- <br /> Inspector signature: Phone number. /(D' —1.+9 )-9a Moto <br /> Necessary or Locally Required Attachments <br /> ff Soil boring logs ®System/As-built drawing 0 Forms per local ordinance <br /> 0 Other information(list): <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • T7Y 651-282-5332 or 800-657-3864 • Available in alternative formats <br /> wrq-wwists4-31 • 1124112 <br />