2009 Septic info - Laserfiche WebLink

Home Browse Search

10/15/2009 16: 15 9528733112 PAGE 01105 Minnesota Pollution Compliance Inspection Form Control Agency S2OLafayee Road North Existing Subsurface Sewage Treatment Systems (SSTs) St.Paul,MN 55155-4194 Instructions on pale Parcel number: For Local Tracking Purposes 1 ' / System status: %Compliant ❑ Noncompliant (based on all compliance requirements) Summary Form 1` r \ % Property Informationn� f Property owner name(s): licz'tj 5 Sa n Sl. h�pcoll Property address; am: ' / . G - -e $ 'o n_04 •dt7 4 ✓ .sio - -—. Property owner's address(if different): —"---� County*l n&p( 4 Property owner phone: Permitting authority: 6*.___ (/Y lLQ (� Date system constructed: 16190 _ Reason for inspection: .L' System Description • Brief system descrlptior(f) 0 - h �O1 cj ct l p um�, , , C�11.91 Local permit number: \ d�� '`�"-=�'--!' �---- Number of bedrooms: 5 _ Design flow rate: �� .._._ Is the system: In Shoreland area? ❑ Yes i) No In Wellhead Protection Area? � ❑ Yes I k1rNo An U.S. Environmental Protection System serving a Minnesota Department rr�� Agency (EPA) Class V Injection Well?0 Yes liO No of Heath (MDH) licensed facility? ❑ Yes Xo Compliance Status (Based on state requirements—additional local requirements may also apply.) JBased on She information gathered and reported on attached forms, the compliance status of this system is (check one) Certificate of Compliance—valid until (3 years from date of report): ❑ Notice of Noncompliance• For Noncompliant systems: The ea son for noncompliance is: Thisnoncompliant system Is classified as (check one below): ❑ Imminent threat to public health 8 safety ❑ Failing to protect ground water 0 Not in compliance with operating perm.: Certification (Completed form must be submitted to the local unit of government within 15 days.) /hereby certify that all the necessary information has been gathered fo determine the compliance status of this system r/c determination of future system performance has been nor can be made due to unknown conditions during system con sit ucaor? possible abuse of the system, inadequtste maint nonce, or future water usage. Name: ---705c Sr1IU( Certification number: R`1D5-4 Business license name and number: jcr)tL} Se l 5 rnL 5.Q ___ or Name of local unit of g er merit: Signature: Date: JOl tJ51 Required Attachments Inspector Complete: This Inspection Report is 5 pages long. Check compliance forms attached: it Hydraulic Performance air Tank Integrity applicable) 'System drawing/As-built drawingany 9 ❑ Soil Separation ❑ Operating what is re Form of ❑An assessment of local requirements that are different from is requirec on :res form x Soil Boring Logs 0 Abandonment form (If appropriate) ❑ other information (lift); • Upgrade Requirements (derived from Minn. Stet. § 115,55)An imminent threat to public health and safely(iTPNS)must be upgrade° rebiacec a • its use discontinued within Ian months of receipt of this notice or within a shorter period I/required by local ordinance.If the system is failing to protea gro..'ip water,(he System must be uppreded,replaced,or its use discontinued within the time required by local ordinance, if an existing system os nor ra,.'.rg as ca;:;-a: - raw,and has of least iwo/eel o/design soil separation.then the system need not be upgraded,repaired,replaced, or its use discontinued.noiival, ger ;:y a^. rota/ordinance mat is more strict. This provision does not apply to systems in shorelsnd areas, Wellhead Protection Areas,or Inose used.n,9n,",Qi' ,;.:...:r •„ oeverape, nd lodging establishments as defined in law, wq•wwists4.3f1 Compliance inspection Form for Exisr;ng SSTs 4/1/08