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ilivio Minnesota Pollution <br />Control Agency <br />520 Lafayette Road North <br />5t. Paul, MN 55155-4194 <br />SSTS Ordinance Checklist <br />Subsurface Sewage Treatment Systems (SSTS) Program <br />Doc Type: Self Audit <br />Instructions: This checklist is to be completed and sent with a copy of the ordinance to the Minnesota Pollution Control 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 Tools Menu/Unprotect Document; for MS Word 2007 <br />users, select the Developer Tab/Protect Document/Restrict Formatting & Editing and click on Stop Protection in lower right corner of <br />screen. (To add Developer Tab to Ribbon, click on the icon 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 />Minnesota Pollution Control Agency <br />Attn: Commissioner's Office <br />520 Lafayette Road North <br />St. Paul, Minnesota 55155-4194 <br />Administrator: Date (mm/dd/yyyy): <br />County Programs <br />Regulatory model chosen: <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 />1. A provision requiring upgrade, replacement, repair, or discontinued use of systems failing to protect ground water as <br />defined in Minn. R. 7080.1500, subp. 4. <br />❑ Included <br />Ordinance citation (page or part number): <br />Upgrade time period: <br />2. A provision requiring upgrade, replacement, repair, or discontinued use of systems posing an imminent threat as <br />defined in Minn. R. 7080.1500, subp. 4. <br />❑ Included <br />Ordinance citation (page or part number): <br />3. If the local unit issues permits to add a bedroom, a provision requiring a Certificate of Compliance (COC) 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 />❑ Included <br />❑ Issue bedroom permits included <br />Ordinance citation: <br />www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats <br />wq-wwists5-11 • 11 / 17/ 11 Page 1 of 4 <br />