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Aug 29 08 04:21 p 763-213-0699 763-213+0695 p,1 �=`.:�;r::-:. Mi�nnesota Pallution Compliance Inspection Form � Control Agency . _ 520 Lafayette Road North Existmg Subsurface Sewage Treatment Systems (SSTS) St.Paul,MNS5155-4194 Instructions on page 7 � Parcel number: �� , �� "L� For Local Tradcing Purposes: r Systern status: �Compliant ❑ Noncompliarrt (based an al!compl�a�ce requiremenls) Summary Form Property Information Property owner name(s): __��o� �GL'L'�� Propertyaddress: /:5��. (�`� � �., �� -. Properiy owners address(rf different): CouMy:�p�n�t� Property owner phone: � �� -�� O�d Permitting authority: Date system constructed: ��,� Reason for inspection: System Description Brief system description: — � S G�' ' d�1p `� .�7i .��'�G� Local peRnit number: Number oF be rooms: � Design flow ra e: ��' ��a[,__ __ Is the system: �1� In Shoreland area? ❑Yes �,No In Wellhead Protedion Area? ❑Yes [$�No An U.S. E�vironmental Protection System serving a Minnesota Departrnent Agency(EPA)Class V Injection Well?�Yes �No oi Heath(MDH)licensed facility? ❑Yes �Na COR1PIidnC@ S�tUS (8ased on state requirements-additionaf local�equirements may also apply.) Based on the informatiun gathered and reparted on attached forms,the corr�pliance status of this system is(check one�: �Certificate of Compliance-valid until (3 years from date of report): ❑Notice of Noncompliance-For Nonoompiiant systems: The reason for noncompiiance is: This noncompliant system Is classified as(check one below): ❑IrnmineM threat to public healt�&safety ❑Failing to protect ground water Q Not in compliance with operating permii C@rt1f1C8tiOl1 (Completed form must be submitted to the local unit of govemment within 15 days.) � 1 hereby certify that a/l the necessary inlormation has been gatherBd to determine the compliance sfatus of this system.No determinatlon of hrture system perfonnance has been nor can be made due to unknown conditi�ons dur+ng system corrstruction, possib/e abuse of the system, inad ate m 'ntenance, or future water usage. Name: � Certification number: ' �� Business li se narne and number: �� ,,� �'�'fC�t �2 � - or Name of local unit of government: Signature; Date: Sj.--_��—G� Required Attachments Inspector Complete:This Inspection Report is�pages long. Check compliance forms attached: �Hydraulic Performance Tank IMegrily '�Soil Separa6on ❑Opereting Permit Forrn(it applica�e) System drewing/As-built drawing ❑M assessmen o any lo�al requirements that are diFf�ent irom what is re�uired on this forrn Soi�ring Logs ❑Abandonment form(If appropriate) ❑Other iniormation(lisl): U�J�8d9 R@qUif A�I'19f1tS(derived�rom Minn. Stat. §115.55J M imminen�threat to public heetth and sa/e!y(ITP►!S)must ba�yraded,rapfaced,or i!s use d'iscarRinued wifhin tan morNNs of receip7 olth/a not�e or wiihin a aho�er perlod if required by local oidinence,H the aystem is faiNr►g to prvfecf gmund wa�r,tAe sysfem musf be up�eded,mplaced,orias use�sconfirwed wi7Nn fhe Ume required by loca!oroVnance.1!an exiafirW�g sysrom�s rrot failing as deHnad in law,and has atleasl fwo leel oldesign sal sep�araUor,,fhen fhe sysfem neeCnof be upgraded,repsirbd,replaced,o�iYs use disconGnued,ndwifhstanding any bcal ordinance iAat is mone siriol,ThFs provrsion does rwt apAly lo sysfema in ahareJend areas,WelYiead P�otecfbn Areas,orJhoae used in connecfion»vth food, beHerage,and bdging esfaWishmen�a as deRned In law. wwists4-3f tamplionce Ins,pectiai Form for Existing SSTS �108