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Minnesota Pollution <br />Control Agency SST's Ordinance Checklist <br />520 Lafayette Road North Subsurface Sawage .Treatment Systems (55TS) Program <br />5t. Paul, MN 55155-4194 Doc Type.- Self Audit <br />Instructions: This checklist is to be completed and sent with a copy of the ordinance .to the Minnesota Pollution .Contro#.Agency <br />(MPCA) Commissioner at least 30 days prior to adoption of the.ordinance. The Commissioner has up to six months to respond. The <br />ordinance may be adopted and implemented during this time. <br />Note: To unlock this form for. editing: for MS Word 2003 users, select the 'fools MenulUnprotect Document; .for MS Word 20l?7 <br />users, select. the Developer`TablProtect Document/Restrict Formatting & Editing and click on Stop.Protection in lower right corner of <br />screen. (To add Developer Tab to Ribbon; click .an theicon in the upper left corner of screen, select Word Options/Popular and <br />check Show Developer Tab.) <br />Submit checklist, list of differences, <br />and a copy of the ordinance to: <br />Local Unit -of Government: <br />Administrator: <br />County Programs <br />Regulatory model chosen: <br />Minnesota Pollution Control -Agency <br />Attn: Commissioner's .office <br />520 Lafayette. Road North <br />St. Paul, Minnesota 55155. 4194 <br />Conventional <br />❑ Performance <br />❑ Alternative Local Standards (for existing systems) <br />❑ Alternative Local Standards (for new or replacement. systems} <br />City, Township, or Other Program <br />County in which. your.jurisdiction lies: <br />Regulatory model chosen: <br />❑ Conventional <br />❑ Performance <br />All Ordinance Requirements <br />Date (mm/ddlyyyy): <br />'!. A provision requiring .upgrade, replacement, repair, or discontinued use of systems failing to protect ground water as <br />defined. in Minn. R,1708011500, .suhp. 4.. <br />❑ Included <br />Ordinance citation (page or part number): <br />Upgrade time period: <br />1 A provision requiring upgrade, replacement, repair, ordiscontinued use of systems. posing an imm€nest threat as <br />defined in Minn. R. 7080.1500.., suhp. 4. <br />❑ Included <br />ordinance citation (page or part.nurnber): <br />3. If the local unit issues perm€ts to add a bedroom, a. provision requiring a Certificate of Compliance (C.00) or Notice of <br />Noncompliance (NON) be Issued on the system prior to issuance of a building permit or variance for the addition of a <br />bedroom. <br />i] included <br />❑ Issue bedroom. permits included <br />Ordinance. citation, <br />www:pca.state.rnn.us. . 651-296.6300 600.657-3.864 . TrY 651-282.5333:or 800-657.3864 Available in alternative formats <br />wq-mWsts5-11 • 11/ 17111 Page Z of 4 <br />