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�/12/2010 08:16 952-955-5071 BURNS EXCAVATING PAGE 03 / <br /> V <br /> r <br /> ��`�? � ���� Compliance Inspect�on Form <br /> � ��,''�iq��esota Polluticn <br /> Control Agency �v$t��9 gubsurfac� Sewage T�aa�tment Systems (SSTS� <br /> 520 Lafayette RoBd North <br /> St Pau1,MAI 55155�794 Doc Type;Comp►lence and Enfon�ement <br /> Instruc�ions on p�ga 6 <br /> Sumn�ary Forn� (Corriple'ted form must De submitbad to the local u�ft of gcvemmerrt within 15 da+ys.) <br /> Perr.el number: <br /> Sysdem�tatu9: �Compfiant ❑Noncompliant <br /> For Local Tracking Putpases: <br /> (based on a!1 c�mpliance iequirements) <br /> Property Information <br /> Property owner neme(s): _ Property owner phone: <br /> Properly address: 700 6�'Street Ave;�North Orono,MN 55391 _ <br /> Property ovmer eddress(it dl�eront)� _ <br /> Ccunty: Hennepin Permittlng authority: Clt�r af Qrono <br /> Date�ysUem constructed: _1998 Reaeon for inspection: Transfer of Title <br /> System Descriptlon <br /> Brief system description: �2)2000 gellon pre-�a�'t se�tic tenks ��compliahce ia only on septic t�nks at�bove location „� <br /> local permit number. Number of b�drooms: 5 Deslgn flow rate; 750 <br /> I�th�aystem: <br /> In Shorelan�i area7 �Yes ❑ No ln Wellhead Probectlon Area1 Q Yes �No <br /> An U.S.Environmen��l Prcrtectfon Syatem serving a Minnesots Department <br /> Aeency(EPA)Class V Injectlon Well?0 Yes � No of Heath(MDH)licensed facilit�/� ❑Yes �No <br /> CGR1P�1anC@ StdtIJS(8ased an state r�squir�ments-addltionel lxal raquiremants m�y a/so apply.) <br /> Baaed on the irYFormation gatAered artd reported on attaChed forms,the compliance status of this system Is(check one): <br /> �CertificaCe�f Compli�nce-valict until(3 years fiom dere of repolt): 10/11/2010 <br /> []Notic�of Noncomplience-For Nancomplfent systems: <br /> The re�son for noncompliance is: _ , <br /> Thls noncompllaat system Is classl�ied as�heck one Aelow): <br /> ❑ lmminent thre�t to public he�{th&safoety Failing to prot�cct ground water ❑Not in compliance wlth operating permit <br /> Certificatjon <br /> 1 hereby certffy thst a/�the necessary ir►Po►matfon hes been gathensd to detennlrre tire comp►iarw�e stetus of this systam. No <br /> d�tarmination of Futur�system peilotmance hes been nor ean be made due bo unknowm condltfons during system cnnsNvction, <br /> possible ebuse of the sysi�m, inadequate malntenence, or futuna water us�ge. <br /> Neme� Pe�nel Hentges Certification number: 2064 <br /> Buelnees license�ame and numbe�. Ch+p's Septfc Senrice LLC or <br /> Name of lacel unit of emm w_ .- <br /> g�9n���; ._^_ _ Date: �10-�1-10 <br /> Requ�red Att�chments <br /> ❑ Nydraulic Performance �Tank Integrity (] Operating Permit Form(if applicab�e) <br /> ❑Soil Boring l.ogs ❑ 5oil Separation <br /> ❑System drawringlAs-built d�awing ❑Any local requirements that are different from what is required on this farm <br /> ❑Other Irriormation(list): , <br /> Upprede Requlrementa(OeriveQ from Mlnn. Stet. §115.55)An lmminant throet eo public heal�h end sefery(lTPWS)must b�upgraded, <br /> replaced,or its u�e discondnued withln t�n monM►s o(racelpt of thls noifce or anthin e shor�er period if required by local nrdinance. If!he sysPam is <br /> faplrr�ta protect grourrd wete►;the syalsm must be upgreded,rvpleced,or Ns use discont/nued wtthin the Hme requ!►ed by locel oralinence, If an <br /> exisfing syslem/s rto!'I'bl/!ng as defined in law,and hes et/east two foet of daslgn sorl separatian,Phen fhe sysfem r►eed not be upgraded,r�peirerl, <br /> repfaced,or!fs use dlsc�nfinuaQ,rtotwlthstendMg�rry Iocef on7inence fhet Is mora stNck 777ie pravlalon does not apply!o sysfems In shor�fand <br /> er�es, Wellhesd P►otecNan Areas,or fhose uaed In conneciion withh food,beverege,end lodgfng e�stabllshments es defirred in IAw, <br /> www.pca,state.mn.us • b51•296-63Q0 • 800-G57-3864 � TTY 651-282-5332 or 800-657-3864 • Avallabl@�n alte�mative formau <br /> n......�.,e o <br />