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May 1710 10:59a 763-213-0695 p.1 rof ,. Minnesota Pollution Compliance Inspection Form Control Agency 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems (SSTS) St.Paul,MN 55155-4194 Instructions on page 7 Parcel number: 1 YQ fl - r R9 For Local Tracking Purposes: System status: A Compliant Q Noncompliant (based on all compliance requirements) Summary Form Property Information Property owner name(s): Property address: 4 (9, 4-124 _0j �- ,•w Property owner's address(if different): A County: 7.1.se-wj t Property owner phone:6 Pg.--7� � 3 7 Permitting authority: Date system constructed: Reason for inspection: System Description r� Brief system description:(2- J 5LN 5 pp r —ot'd q ' f3 s-v? i._aap�,,�,u�,iy T re'6 ll Local permit number: Number of bedrooms: Design flow rate: Is the system: In Shareland area? NJ Yes ❑ No In Wellhead Protection Area? ❑Yes (a No An U.S. Environmental Protection System serving a Minnesota Department Agency(EPA)Class V Injection Well?❑Yes 1:4 No of Heath(MDH)licensed facility? ❑ Yes kNo Compliance Status (Based on state requirements-additjonal local requirements may also apply.) Based on the information gathered and reported on attached forms, the compliance status of this system is(check one): 010 Certificate of Compliance-valid until years fromtiateifresort): ❑ Notice of Noncompliance-For Noncompliant systems: The reason for noncompliance is: l This noncompliant system is classified as (chebk one below): ❑ Imminent threat to public health.&safety Failing to protect ground water Not to compliance with operating permit Certification (Completed form must be submitted to the local unit of government within 15 days.) I hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No determination of future system performance has been nor can be made due to unknown conditions during system construction, possible abuse of the system, inadequate maintenance, or future water usage. Name: �. ,�° 1 Certification number: Business license name and number: ' [ ddo,e�,e�C' N2+14. i ?23 or Name of local unit of government: Signature: 411h • ! _ ,,► Date: 1 -- — Required Attachments Inspector Complete: This Inspection Report is i pages long. Check compliance forms attached: Hydraulic Performance CI Tank Integrty Soil Separation 0 Operating Permit Form (if applicable) Vj System drawing/As-built dr wing ❑An assessment df any local requirements that are different from what is required on this form flci Soil Boring Logs ❑Abandonment form(if appropriate) 0 Other information(list): Upgrade Requirements (derived from Minn.Stat. §115.55)An imminent threat to public heailh and safety(ITPHS)must be upgraded,replaced,or its use discontinued within len months of receipt of this notice or,vilhin a shorter period if required by local ordinance. If the system is failing to protect ground wafer, the system must be upgraded,replaced,or its use discontinued within the time required by local ordinance.If an misting system is not failing as defined in law,and has at least two feet of design soil separation,then the system need not be upgraded,repaired,replaced,or its use discontinued,notwithstanding any local ordinance that is more sirict. This provision does not apply to systems in shoreland areas,Wellhead Protection Areas,or those used in connection with food• beverage,and lodging establishments as defined in taw. wq-wwists4-31 Compliance Inspection Form for Existing SSTS 4/1/08