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� MinnesotaPollution Compliance Inspectian Form
<br /> Cont�ol Agency
<br /> k 520LafayetteRoadNonh Existing Subsurface Sewage Treatment Systems (SSTS)
<br /> S�.PauI,MN55155�194 � InsCructions an page '
<br /> PdrCel number: Fo�LOcal Tracking Purposes
<br /> System status: ompliant ❑Noncompllant
<br /> (based on aH com liance requirements) / � '
<br /> !/.
<br /> Sutnmay �orrt� ��(
<br /> Property Informat9on � r �� - -
<br /> Property owner name(s� l�1
<br /> Property address; � "' �
<br /> Praperty owner's address(if different); __,._ _.,__..._., .
<br /> County: 1n�, P perry owner phone: q�,��T/3" 33 Permi�ing authc�ity: C•1� .__,�_,_,_,.� , ,
<br /> �ate system const ctad: Reason fo�inspection; ___,.__._,_. „ „
<br /> System Description ,
<br /> Brie(system description: ���. GJ � 121 0 tJ�
<br /> l.ocal pem�ii number: Number of bedroom : � Design flow rate: _� .
<br /> Is the sy�stem: ��
<br /> in Shorsland area? ❑Yes �No In Wellhead Protectlon Area? ❑ Yes JI�� No
<br /> An U,S. Environmental Proteclion System serving a Minnesota Department � �
<br /> Agency (�PA)Class V InjeCtion Well?�] Yes �No of Heath(MQH)licensed faciliry? � Yes �No
<br /> Compll+��Ce $tdtU4(Based on state requirements—additiohal local requi�ements may also apply.)
<br /> Based on the infonnation gathered and rsported on sttached fo�ms,the compliance status of this system is(cneck onc�
<br /> �Ceniflcate of Compllance—valid until (3 yvars from date ol repo�: __,.__.__,. ... .
<br /> ❑ Notice of Noncompliance- For Noncompliant systems:
<br /> The reason tor non�mpliance is� ._,_.. . .. . ,
<br /> 7hls noncompliant system is classiffod as (check one below):
<br /> Q Imminent threst co public health 8 sefiety � Failing to proteet ground water ❑ Not in compliance wiih op�rauny p�rn,�
<br /> C2t'ttfiC8t1011 (Completad fonn must be submltted to the local unit of govemment within 15 days.)
<br /> �hereby certify thaf all rhe necessary inlormation has been gafhered fo determine the compl;ance stalus of rh�s sysreri; �,:
<br /> defermina(ion o!future syStem pe�ormence has been nar can be mede due!o unknawn Condiflons during sys�err�constr����,:.��
<br /> possib/e abuse of the sysfam, inadequ fe mainlenence, or future water usage. ��
<br /> Name: _. L1CJ� ���"����(1� --- Certification number; ,���,_ .., . ,
<br /> Business license name and number: Sl�+r��r1r� SQ�l�„���C� �a. ___ . .... , _ or
<br /> Name of local unit ov e ^ ., . ._ . .
<br /> . , . ..
<br /> Signaiure: � Date: �..��. ....... _ ......... .. _.
<br /> Required A tachments Inspector Complete:This Inspection Report is �page5 long.
<br /> Cheek�omplianae forms attached: �ydrdullc Partortnance �'ank Integrity �Soil Separdtlon ❑Operating Perm�i F�rm�,?
<br /> applicable) tem drawing/As-built dra�vinp ❑An assessmenl of any Iocal requiremBnts that are different irom whai�s reC��reo on;r�s
<br /> form �So Boring Logs ❑Abandonment lotm(i/approprlate) ❑Olher inlormaUon (I�t)_
<br /> Upgrade Requirements(derived irom Minh. S�at. §•115.55)An immJnenl tArool lo public heatlh and aa/ery(ITPhIS)musi Oe upg�aaea.ie��acec :-
<br /> �fs usa 0lscanlinued wilAin len+nonfh�ol nceipf of IAAs�olks oi wifhin i ahorfei pariod il iequired oy local adin�►nce.fr Ine tylfem,a/a�tmg ra pro�e:r;�o..rr
<br /> Marei,I�e syalem mus10�upniad�d,nplaead,aifa yae diacanlinu�d wilhin U+e lime requirod by laea/ordinancr,!l 8n err'Sling sysiem�S nor far�,r;�s:e::r•:: ••
<br /> faw,and nss af�eas!Iwo leel ol d�sipn Job�sperafiab.Ih�n Ihe syslem noed noi De upQraOed,rspairod,rcD�eeod,or ils use oiscom�nueo.norw��r:s:�:�:•::;�^,
<br /> locai ordi�8nee lnal is mora suicf. TAIs Drovi�ion dasq nof spply lo ty8fems in tnore�ano areas,WalMe�rd PiOfeCUon Areas,oi rnose usea�r+:a�+r.�:r;.:: .�•�••:__
<br /> �ove�oga.ana iodginq sa�a0lisl+msnfs as ee�inad in bw.
<br /> wq-wwists4•31 Compfiance Inspec�ion form far Ex�s:�•^•q SST�
<br /> al1I08
<br /> 50/Z0 3�JGd ZZiEEL8Z56 6Z�bT TZ0Z/99190
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