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q�Th <br /> Minnesota Pollution <br /> Compliance Inspection Form <br /> Control Agency <br /> 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems <br /> St,Paul,MN 55155-4194 (SSTS) <br /> Doc Type.Compliance and Enfo; meat <br /> Instructions: Inspection results based on Minnesota Pollution Control Agency(MPCA) For local tracking purposes: <br /> requirements and attached forms-additional local requirements may also apply. <br /> Submit completed form to Local Unit of Government(LUG)and system owner <br /> within 15 days <br /> System Status <br /> System status on date(mm/dd/yyyy): 7/20/2018 <br /> ® Compliant— Certificate of Compliance ❑ Noncompliant— Notice of Noncompliance <br /> (Valid for 3 years from report date, unless shorter time (See Upgrade Requirements on page 3) <br /> frame outlined in Local Ordinance.) <br /> Reason(s)for noncompliance (check all applicable) <br /> ❑ Impact on Public Health (Compliance Component #1)-Imminent threat to public health and safety <br /> ❑Other Compliance Conditions(Compliance Component#3)-Imminent threat to public health and safety <br /> ❑Tank Integrity(Compliance Component #2)-Failing to protect groundwater <br /> ❑Other Compliance Conditions(Compliance Component#3)-Failing to protect groundwater <br /> ❑ Soil Separation(Compliance Component #4)-Failing to protect groundwater <br /> ❑Operating permit/monitoring plan requirements(Compliance Component #5)-Noncompliant <br /> Property Information Parcel ID#or Sec/Twp/Range: 0411723240002 <br /> Property address: 225 Old Crystal Bay Road S.,Orono,MN Reason for inspection: New Construction <br /> Property owner: Jason Pitts Owner's phone: <br /> or <br /> Owner's representative: Gordon James Representative phone: 763-479-3117 <br /> Local regulatory authority: City of Orono Regulatory authority phone: 952-249-4600 <br /> Approximately 1-1000, 1-1000 gallon septic tanks,1-1000 gallon lift station and 625 square feet of <br /> Brief system description: mound rockbed. <br /> Comments or recommendations: <br /> TBM:Top of S.W.Corner iron EL-996.4.The existing system has 1.3 feet of sand.The existing tanks are to be abandoned. <br /> Certification <br /> I hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No <br /> determination of future system performance has been nor can be made due to unknown conditions during system construction. <br /> possible abuse of the system,inadequate maintenance, or future water usage. <br /> Inspector name: Joseph J Olson Certification number: 1255 <br /> Business name: Rusty 01 on's Soil&Perc.Testing License number: 810 <br /> Inspector signature: Phone number: 763-498-8779 <br /> Necessary or Locally Required Attachments <br /> ►C+ Soil boring logs ®System/As-built drawing 0 Forms per local ordinance <br /> ❑Other information(list): <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-wwists4-31 • 1/24/12 Pose 1 of 3 <br />