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Minnesota Pollution Compliance Inspection Form <br /> Control Agency <br /> 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems (SSTS) <br /> St.Paul,MN 55155-4194 Doc Type:Compliance and Enforcement <br /> 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(mmlddlyyyy): 6/19!2018 <br /> (l' 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' 2311723320060 <br /> Property address 360 Big Island, Orono MN Reason for inspection, Property Transfer <br /> Property owner T P Egan&C A Egan Owner's phone: 612 363 3350 <br /> or <br /> Owner's representative Representative phone <br /> Local regulatory authority. Regulatory authority phone <br /> Brief system description: <br /> Comments or recommendations: <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 dunng system construction, <br /> possible abuse of the system, inadequate maintenance. or future water usage <br /> Inspector name Paul Bra Certification number, 5182 <br /> Business name. Soil tnvesti tion &Design, Inc License number 3263 <br /> Inspector signature: / Phone number 651-260-3783 <br /> Necessary or Loc y Required Attachments <br /> El Soil boring logs El System/As-built drawing ❑ Forms per local ordinance <br /> Other information (list). Water tightness testing results <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-wwists4-31b • 6/4/14 Page 1 of 3 <br />