2009 - MPCA compliance inspection form

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lillW a ;. Minnesota Pollution µ control Agency Compliance Inspection Form 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems (SSTS) St.Paul,MN 55155-4194 Parcel number For Local Tracking Purposes: System status: Compliant ❑ Noncompliant (based on all co pliance requirements) Summary Form L ,.... Property Information � Property owner name(s): Property address: a QQ Property owner's address (if different): County: 144 4/40, Property owner phone: 9� ' Permitting authority: •QQ,r�-o Date system constructed: 7 / Reason for inspection: 5-R!, System Description Brief system description: S`C/I T,L �,�1� a9V r.A y74'64#A7-0 ,/< .L 4 `o Kr•0R N� Local permit number: / ! / •�/�bt� / '/� Number of bedrooms: Design flow rate: (�_a Is the system: In Shoreland area? ❑Yes ErNo In Wellhead Protection Area? ❑Yes dNo An U.S. Environmental Protection System serving a Minnesota Department (t7 No Agency(EPA) Class V Injection Well?❑ Yes L� of Heath (MDH) licensed facility? ❑Yes No Compliance Status (Based on state requirements-additional local requirements may also apply.) Based on the 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 reason for noncompliance is: This noncompliant system is classified as (check one below): ❑ Imminent threat to public health &safety ❑Failing to protect ground water ❑ Not in compliance with operating permit Certification (Completed form must be submitted to the local unit of government within 15 days.) I hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No determination of future system performance has been nor can be made due to unknown conditions during system construction, possible abuse_of the system, inadequate maintenance, or future water usage. Name: �o`j<.�� k�fist/ ��j • - Certification number: fo Business license name and number: 24 [ �+ q Name of local unit of 1overnment: _- Signature: 1_. q Date: (iZ/g� l Required Attachments _ ---_ Inspector Complete: This Inspection Report is '- pages long. Check compliance forms attached: YJ Hydraulic PerformanceP 9 applicable DTank Integrity Soil Separation .Operating Permit Form(if ❑System drawing/As-built drawing ❑An assessment of any local requirements that are different from what is required on this form Soil Boring Logs QAbandonment form(if appropriate) 0 Other information(list): Upgrade Requirements (derived from Minn. Stat.§115.55)An imminent threat to public health and safety(ITPHS)must be upgraded,replaced,or its use discontinued within ten months of receipt of this notice or within a shorter period if required by local ordinance.If the system is failing to protect ground water,the system must be upgraded,replaced,or its use discontinued within the time required by local ordinance.If an existing system.is not failing as'defined in law,and has at least two feet of design soil separation,then the system need not be upgraded,repaired,replaced,or its use discontinued notwithstanding any local ordinance that is more strict. This provision does not apply to systems in Shoreland areas, Wellhead Protection Areas,or those used in connection with food, beverage,and lodging establishments as defined in law. w-wwists4-31 /1/08 •Compliance Inspection Form for Existing SSTS