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r ' ' 5, [Vihinesota Pollution <br /> Compliance inspection Form <br /> Control Agency Existing Subsurface Sewage Treatment Systems <br /> 520 Lafayette Road North <br /> St.Psui,MN 55155-4194 (SSTs) <br /> Doc Type:Compliance and Enforcement <br /> Instructions: inspection results based onMinnesota 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): 3 -a a- <br /> Compliant—Certificate of Compliance ❑ Noncompliant-Notice of Noncompliance <br /> (Valid for 3 years from report date,unless shorter time (See Upgrade Requirements on page 3) <br /> frame outlined in Local Ordinance.) <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 /> o Tank integrity(Compliance Component #2)-Failing to protect groundwater <br /> ❑Other Compliance Conditions(Compliance Component#3)-Failing fo protect groundwater <br /> 0 Soil Separation(Compliance Component #4)-Falling to protect groundwater <br /> ❑Operating permit/monitoring plan requirements(Compliance Component #5)-Noncompliant <br /> Property Information Parcel ID#or Secrfwp/Range: <br /> Property address: Sd Ov9 4-0441744-- Li s{ '0.5,1‘014, 4,) Reason for Inspection: f 49 ..? <br /> Property owner: Slut c Owner's phone: <br /> or <br /> Owner's representative: (...144,4 SAW 1 GNP Representative phone: t,vl-'"a#10 )o o t <br /> Local regulatory authority: dam- q•4171_, Regulatory authority phone: 'hos - a.49-Moo <br /> Brief system description: a-10042. c -A.c.'On-840-47 /V ad «1 ?L1ti4.41,�. 5-€+ <br /> Mta,au.1ot- , <br /> Comments or recommendations: S4s dw1 4,4 4 10,x 54' ogns W4. H't Qovw, 14 0 <br /> Certification <br /> 1 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 /> possibleabuse of the system,inadequate maintenance,or future water usage. <br /> Inspector name: yfe/y{�j, ' \ Certification number <br /> Business name: 4 <br /> License number <br /> Inspector signature: Phone number ')i - <br /> y ct -' 5 tnt,, <br /> Necessary or Locally Required Attachments <br /> 11 Soil boring logs ®System/As-built drawing Q Forms per local ordinance <br /> ❑Other information(list): <br /> ritt?CaltUar • OVUM • 015T•3164 I ITT 651.16I'533Z v100157.3861 ' available in alterative formats <br />