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Apr 22 1011;59a 763-213-0695 p.1 , 3 � : Minnesota Pollution Camp[iance Ir�spect�on �'orm �.�:�«.� `��`�°� �- Control Agency 520tafayetteRoadNorth Existing Subsurface Sewage Treatment Systems �SSTS) St.Paul,h1IV 55155-4194 Instructions on pa�e 7 Parcel number; � � l`, P � .J1�LN�� For Lacal Tracking Purposes: System status: � Compl3ant ❑ Noncompliant (based on al!compliance requrreme,�ts) Summary Form Property Information Property owner name(s): � PropeRy address: 7� � P �'�'�� Property owner's address(it ditferent): County: Properiy owner phone:9,r��y"fl�-P� Permitting authorlty: Date system constructed: f_�(a(�� Reason for inspection: � � System Description r Brief system description: - 3oa _ � D 00 Q'u�6' Local perrnif number. Number of bedro ms: Design Flow rate_ Is the system; fn Shoreland area? Q Yes �f No In Wellhead Protection Area? ❑Yes [X'j No An U.S. Environmental Protection Systerrt serving a Minnesota Department Agency(EPA)C1ass V Injection Well?�Yes � No of Heath(MDH}licensed facility? ❑Yes � No CORIP�laC1Ce StdtUS (Based on state re�uirements-additional local requirements rnay also apply.} Based on fhe information gathered and repo�ted on atiached forms, the compliance slatus oF Ehis system is (check one); �CertiEicale of Compliar,ce-valici unlil (3 years frorrr date of reporfl: �� ot� -f.3 - - ❑ Notice of Noncompliance-For Noncompliant systems: The reason for noncornpliance is: This noncompliant system is classified as(check one below): ❑ Imminent threal to public health & saFety ❑ Failing to protect ground water ❑ Not in compliance with operating permii CE'ftlflCdt1031 (Completed fr�rm must be submitted to Ehe local unit of government within 15 days.) 1 hereby certify that all the necessary informafron has been gathered to defermine!he compliance status of ihis sysfem. No determrnation of fufure system performance has been nor can be made due to unknown condifions dunng system constrUctron, possible abuse of the system, inadequate marntenance, or future water usage. "'�'�� 1 Certification number: � � �J Name: n o a P / B�siness license name and number .�_/Il��,�fi��/� (�55�_, c:'��1✓C ��_ or Name of'o�:.al unit of government: Signaiu•e: � Date: �= 2 / — /-U Required Attachments Inspector Complete: This Inspection Report is pages long. Check compl�ance forms attaGhed: �1 Hydraulic Per`ormance (� Tank Integrity �Sail Separallor. ❑Operating Permit Form(if applicablej �System drawinglAs-buil!drawing ❑An assessmenl of any local require ents that are difterent irom what is recuired on this forrr �Soil Borrg Lcgs ❑Abardonme�t form(if appropriate) ❑O:her informa:ion llist;: l}pgrade Requirements (denved from Minn. Sfat. 6�15.55)an�nminenr inrear;o public heailh ar,d safety i17PH5)musf be upgraded,replaced,or T its us?discan6nued wi(hir,!en mor.ths cf receipf o(this notica or wiLhin a shorter pe•iod if reqerired by lowl ordinance.11 the syst=m is laifing ro orolecl grovrrd warer,ths sys(em must b�upgraded,replaced:or its use disceminued wifnin the time required by local orCinance. f!an exisfing sysfem is not�ailing as defined in law,and has af�eas(tx�o 1ee�of desiGn sor!sepzrarion,lher,tha system need r.of be upgraded,�epaired, replaced,or ifs uso disconl�nued,notwrthslanding any local ordmance(ha!rs mo;e sbict This pravision dces no(app�y.'�sys�ems rn shoreland areas, W'elihBad Prolecl?on Areas.or those used in ccr�neclren wrlh lood. beverage.a�d lodging eslabfishments as der�ned rn Jaw. wq-wwrsts4-31 Compfiance Inspection Form for Existing 55T5