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08/01/2008 05:33 7634975011 SPTESTINGINC PAGE 02105 1 :;;, Minnesota Pollution 0M p Hance Inspection Form ;►�xk -Control Agency 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems (SSTS) St.Paul,MN 95155-4194 Instructions on page 7 Parcel number: For Local Tracking Purposes: System status: ❑ Compliant S Noncompliant (based on alf compliance requirements) Summary Form Property Informatio Property owner name(sy % r� � *,� sp�A Property address: � � Property owner's address(Ndiffe�renq: County:X11 Property owner phone; Permitting authority: La'f or - _Lb_ t9'P-t�s.l u Date system constructed: .__)_cl,!2 q Reason for nspection: System Description Brief system description: _ a --low !W ___-0 960 5 a f2!C U F Local permit number: Number o r bedrooms: „ Design flow rats: DOC) Is the system: In Shoreland area? Yes ❑No - In Wellhead Protection Area? [--]Yes No An U.S.Environmental Protection System serving a Minnesota Department Agency(EPA) Class V Injection Well?❑Yes M No of Heath(MDH)licensed facility? ❑Yes No Compliance Status(Based on state requirements—addi ional 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 i f report): IIn Notice of Noncompliance-For Noncompliant systems: The reason for noncompliance is: This noncompliant system is classified as(check o ne below): ❑ Imminent threat to public health&safety ® Fallin to protect ground water ❑Not in compliance with operating permit Certification(Completed form must be submitted to the to ml unit of government within 15 days.) I hereby certify that all the necessary information has been g athered to determine the compliance status of this system.No determination or future system performance has been nor ca i be made due to unknown conditions during system construction, possible abuse of the system,inadequate maintenance, orf fum water usage. Name: � ,��, ( � Certification number: Business license name and number: 5 —� '��'i LCL �� ?,�9��? , r � or Name of local unit of govern ent., Signature: ��-- V'Date; rIT30 D`� Required Attachments Inspector complete:This Inspection Report is pages long. Check compliance forms attached; 0 Hydraulic Performance ❑TaNc Integrity N Soll Separatlon ❑Operating Parmit Form(If applicable) IN System drawing/As-built drawing ❑An e3se"r iont of any local requirements that are different from what is required on this form N Soil Boling Logs ❑Abandonment form(if appropriate ❑Other Infornatlon(11m):"00 Upgrade Requirements(derived Dom Minn.stat.§195,55) 4n Imminent threat to public health and solely(i7PHS)must be upgreded,replaced,or !ts vse dimonrinued within ten montlis of recelpt of this notice or within a i thoner period ifrequhed by local ordinance.If the system is felling to pmtsot ground water,the system must be upgraded,replaced,or its use dlsconflnued wh h1h the Ilmd required by local ordnance./f an exlatlng system is not railing as del/ned In law,and has at/most two foot of dss/gn soAseparallon,then the system n not be upgraded,repaked,replecao;or Hs use discontinued,nolwlthstending any local ordinance that/s more shot'rhts ptoviston does not apply to systerr,a in Mormland ages,Wellhead PAVocaon Ar4w.%or Motto used M oonneeBon wUh rood, beverage,and lodging eatabllahments a*defined in law. wq-wwists4.31 Compliance Inspection Form for Existing SSTS