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0510912011 10:05 9528733112 PAGE 01/04 <br /> Minnesota Pollution Compliance Inspection ControlAgency p tion Form <br /> 520 Lafayette yNteRoad <br /> 5.g194 h Existing Subsurface Sewage Treatment Systems (SSTS) <br /> St,Paul,MN 55155.4194 <br /> Parcel number: <br /> Instructions on pave <br /> �c <br /> System status; Compliant [] Noncompliant V For Local Tracking Purposes <br /> (based on all compliance requirements) <br /> J. <br /> Summary Form <br /> Property Information <br /> Property owner name($): <br /> Property address; 3 0 <br /> Property owner's address (it different); ---- <br /> County; jL Property owner phone: -�1��ZlQ <br /> Date system constructed: Permitting authority: <br /> Reason for inspection: - -- <br /> System Description <br /> Brief system description: <br /> Local permit number; <br /> Number of bedrooms: 3 Design flow rate; <br /> Is the system: D __. •._ <br /> In Shoreland area? <br /> ❑Yes [ No In Wellhead Protection Area? �I <br /> An U.S. Environmental Protection ❑ Yes AlNc <br /> Agency(EPA) Class V Injection Well?❑ Yes Ne of Heath(MON)System serving a rose facility?partment nsed <br /> 0 Yes/KNa <br /> Compliance StatUS (Based on state requirements—additional local requirements may also apply.) <br /> �Based on the information gathered and reported on attached forms, the compliance status of this system is (check one. <br /> rtiftcate of Compliance—valid until (3 years from date of report); <br /> ❑ Notice of Noncompliance -For Noncompliant systems: — --- — <br /> The reason for noncompliance is: <br /> This noncompliant system 1S classified as (check one below); —11 Imminent threat to public health &safety U Failing to protect ground water ❑Not in compliance wilh Operating perm.: <br /> CC rtification (Completed form must be submitted to the local unit of government within 15 days.) <br /> I hereby certify that all the necessary information has been gathered to determine the compliance status of this sysrerl, Jc <br /> determination of future system performance has been nor can be made due to unknown conditions during system car srr;;cf,;:r <br /> possible abuse of file system, inadequate maintenance, or future water usage. <br /> Name: — ��sq <br /> - � Certification number: <br /> Business license name and number: � _ 1� O� . . . <br /> Name of local uni over ent; - _.... .. or <br /> Signature; �— ---- <br /> _ Cates �. 1.r ..... <br /> Required Attachments Inspector Complete: This Inspection Report is Pages long. <br /> Check compliance forms attached, �'draulic Performance �ank Integrity Soil Separation P 9 <br /> mii Pori, 1,f <br /> applicable) stem drawing/As-built rd awing ❑An assessment of any local requirements that are differ❑eni from tw aP is eco rec on :r*,z <br /> forth ❑Sofl boring Logs Q Abandonment form(if appropriate) ❑ other Information(liyt): <br /> r <br /> Upgrade Requirements(derived Inpm Minn. Stat. §115.55)An imminent theaf to public health and safery(1TPHsl must be upgraeeo,rep acec <br /> as use Oiscontlnued with/n fen months o/reeelpr aphis notice or within a ahoner rtod if re uired b local ordinance. it(nes stem i <br /> Nater,ane system n+usl be upOmdad,replaced,or its vse disconlinued within the lime required by Joest ordineneo,iron existing systema sng to t fa rocs as7c=r::=: <br /> lair,and has ar feast two feet Ordesiyn soil SeparaLon, then(no system need nor be upgraded. Y loco d,r ino ce. or its use d�sconunuPd.no;w:trs� .;y j..• <br /> local ordinance That is mare sffict, This provision does nol apply Io syslems in shoreland areas. Wellhead Prprecd, Areas,or inose vsea r ;,�n.,$; „ •,• <br /> beverage, and lodging es1a611shh1onfs as der in law <br /> wq-wwi5ts4.31 Compliance Inspection Fnrm (r)r F.jc-!nc i;T( <br />