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Minnesota Pollution Compliance Inspection Form Control Agency 520 Lafayette Road North Existing Subsurface Sewage-Treatment Systems (SSTS) St.Paul,MN 551SS-4194 n' Instructions on page r Parcel number; .1 (` For Local Tracking Purposes System status: ' CompNant 0 Noncompliant A.) (based on all co fiance requirements) <' f17Summary Form Property Information Property owner name(s): i Ce. ... . ......_ _. Property address: 1,290 i)I CNK) �n`�o - CX?,1140 _-- ..__.. __. Property ow er's address(if different): County: l Property owner phone:d/Q? —/, ermitting authority: ei Date system conscult ted; )99 IS Reason for inspection: System Description n Brief system description: 1-4,619 t, voyi .- /f/yam(/ Local pemiit number: Number of bedrooms: —V Design flow rate: _..6029 Is the system: In Shoreland area? 0 Yes No In Wellhead Protection Area? 0 Yes No An U.S. Environmental Protection System serving a Minnesota Department Agency(EPA)Class V Injection Well?0 Yes&o of Heath(MOH)licensed facility? 0 Yes J 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): 0 Notice of Noncompliance-For Noncompliant systems: The reason for noncOmpliance is: This noncompliant system is classified as (check one below): 0 Imminent threat to public health&safety 0 Failing to protect ground water ❑ Not in compliance with operating perp:.! 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 fo 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 consrructot: possible abuse of the system, Inadequate maint nance, or future water usage, Name: __ ��, �l]Pr^)�l�t,� Certification number; MU)6Cl_._. Business license nam and number: f j( ..S `re_ oa- __ ., or Name of local un' gov ent: _ __ Signature: • Date: 3 / .7 ._.._. .. Required ttachmefits Inspector Complete:This Inspection Report is pages long. Check comp) a forms attached: jydreulic Performance Tank Integrity Soil Separation 0 Operating Permit Form t.i applicable) drawing/As-builfydraw`ing ❑An essessme off any local requ entente that are different from what is required on tats form ❑ So Boring Logs ❑Abandonment form(if appropriate) 0 Other information OW): Upgrade Requirements(denved from Minn. Sial.§115.56)An Imminent threat to public health and safety(ITPhis)must oe vpgradro.reptacec, its use discontinued►a'NIo len months of receipt or this notice or within a spoiler period ii required by local ordinance.if the system is led ng to protect groune water,the system must be upgraded,replaced,or its use discontinued within the lime required by local ordinance.It an existing system is not tad:tty JS termer - law,and has at least two leer Of design soli separation.then the system need nor or upgraded,repaired,replaced.or its use discontinues nos+.:u1s:y::a:::q a tocol ordinance That is more strict. This provision deet not apply to systems in shoreland areas, wellhead Protection Areas.or those used:0:ont,r,:fir:,.,:f••::: 'sewage.and lodging estabNxhments as defined in law. erq•wwists4.)1 Compliance Inspection form for Exis:!rg SSTS 411108 S2/T0 3DVd ZTTEEL8Z56 Zb:ET ZTOZ/EZ/E0