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BS/19/2014 15:49 9528733112 PAGE 01/04 <br /> �v <br /> �� Minnescta pvllution � � ��mpliance I nspection Form <br /> ontro�agenc�r <br /> 52d Lafay�tte Rpad Nprth Exlst��g �iubsurface Sew�ge Treatment Systems (33T$) <br /> St.Raul,MN 551SS-4194 Dac Type:Compliance and Enfor�ement <br /> In9pection reSults based on Minnesota PoAution Control Agency(MPGA) j For IoCal tracking purpo�es: <br /> requiraments and attached forms—additional local requirgm�rits may alsa apply. � <br /> 3ubmit completed lorm!o Local Unit of Government(LUG)2�r�d,Systerta owner I <br /> within 15 d�ys ' <br /> System Status <br /> System status on dete(mm/ddlyyyy): S/14/2014 <br /> � Compliant�-C�rtificate of Comptia�nce ❑ Nancompliant— Notice of Nonccmpliance <br /> (Valid for 3 years from rBpart date,unless shorter fime (See Upgrade Requirements on page 3.J <br /> fr�m�putJin�d in�Laca!Ordinance.) <br /> Reason(s)for noncompliance (check all applicable) <br /> ❑ I mpact on Public Heafth (Complranc�GOmp4nQnt#7)—fmminent threat to pubGc health and safery <br /> ❑Other Compliance GOnditions(Gompli�ncB Cor»ponent#3)—lmm�nent threat fo publlc health and safefy <br /> ❑T2nk Int9grity(Complrance Componenf#2)—Failing to protect groundwaler <br /> ❑ Oth�r COmpI��nC�COnditions(Complianca Gomponent�3)—Faiffng�o protect groundwater <br /> ❑ Soil Separation (Compli�nCe Cornpon�nt#�)—Failing to protect groundwafer <br /> ❑Operating permidmonitoring plan rAquirgments(Gomplianca Componeni#5)—No�compliant <br /> Property Infnrmation Parcel ID#or Sec/'I"wp/Range: <br /> Property address: 760 D�Lake Drive, C)rono Re�son fpr inspection: Sale <br /> Property owner: Abraharr�Thomas Owner's phone: <br /> ol' <br /> pwngr'S rgpres9ntative; Representative phone: <br /> Local regulatory authority� Giry Regui2tory authority phone: <br /> Brief system description: 1250& 1000 septic&1250 pump tank mound system__ <br /> '------ - . _ <br /> Comments ar recommendetiana: <br /> Certification <br /> 1 her�by certify that a!!1he n�cassary information has been g�tirered to defermine fhe aomplrance sPatus of fhis sysfem. No <br /> determination of fufure syst�m perform�nce has bee»norcan be made due to unknow�conditions during system constructron, <br /> possible abusv�of the systam, inadequate m�ir�ten�noe, ar future wafer usage. <br /> Inspector name: Josh Swedlund Certification number; C1659 <br /> Bus�nesS namA' Swedlun tiC rvi License number: 2502 <br /> Inspector slgnature: Phane number: 952-873-3292 <br /> Netessary or Lo Ily Required Attachments <br /> �Soil boring logs �System/As-built drawing � Forms per local ordlnance <br /> ❑Other information (fist): <br /> www.pca.s[aCe.mn.us • 651•246-6360 • 800•657-3864 • TfY 651-282-5332 o�$00-557-3864 . AvaSldble in dlCerndY.ive fo�mdt5 <br /> wq•wwists4-31 • 3/16/12 Page 1 of 3 <br />