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Jun 28 2015 03:47PM HP FaxRusty Ols«i 7634988290 page 2 <br /> �r�.� <br /> � Minnesota Po�lution Compliance Ins ection Form <br /> Cantrol Agency p <br /> 520 Lafayetto Road North Existing Subsurtace Sewage Treatment Systems <br /> St Pdt�,MN 55155-4194 �ssTs' <br /> Doc Type•Compliance and Enfwcemant <br /> Instructiona: Inspection results based on Minnesota Pollut(on Gontrol Agency(MPCA) I For local tr D <br /> requirements and attached forms-additional local requirements may also apply. I <br /> Submit completed fonn to Local Unit of Government(�UG►and sysbem owner �UN 2 9 20�� <br /> virithin 15 days � <br /> .cmroFORONo <br /> Systern Status <br /> System status on date(mmldd/yyyy); 6125l2015 <br /> ❑Compliant-Certificate of Compliance � Noncompliant- Notice cf Noncompliance <br /> (Valid for 3 years from r�port date, unless shorter dme (See Upgrade Requirerr�nts on page 3) <br /> frarne ouBined in�ocal Orclinance.) <br /> Reason(s}for noncompliance(check a!1 appNcable) <br /> ❑ Impact on Public Health(Compliance Componenf #1)-lmrn�nent threaf to public health and safety <br /> ❑�ther Compliance Cortditions(Compliance Component#3)-Imminent throat to public health a�d safery <br /> ❑Tank Integrity(Complrance Component #2)-Failing to protect groundwater <br /> ❑Other Compliartce Cond'Nions(Compliance Component#3)-Farling fo profect groundwater <br /> �Soil Separation (Compliance Component #q)-Failing fo protecf groundwafer <br /> ❑Operating permitlmonitoring plan requfrements(Compliance Component #5J-Nancpmpliant <br /> Property Information Parcel ID#or SeclTwp/Range: 3311823420002 <br /> Property address: 2790 Silver View Drive. Orono, MN Reason for inspection: Property Transfer <br /> Property owner: Patridc Coughlin � OwnePs phone: 651-245-3141 <br /> or <br /> Owner's representative: Representative phone: <br /> Local regulatory authoriiy; Ci af Orono Regulatory authonly phone: 952-2�9-460p <br /> Brief system descriptlon: 2-1000 allon tic tanks and a roximaiel 1350 lineal feet of trench er cl records <br /> Commenls or recornmendations: <br /> Certificatlon <br /> l hens6y ceriify tha�aN the necessarylnfortrra6on has been gathered to determine the compliance status of this system.No <br /> determination of futu�system pertormance has been nor can be made due to unknown conditions during system construction, <br /> possible abuse of the system,inadequahs maintenance, orfuture water usage. <br /> Inspector name: Joseph J Oison Certification number: 1255 <br /> 8usiness name: _Rusty Olson's Soil&Perc Testinq License number: 810 <br /> Inspector signature: _ A Phone number: 763-498-8779 � <br /> Necessary or Locaily Required Attachments <br /> �Soil boring bgs �System/As-built drawing ❑Fort�ns per local ordinance <br /> ❑Other information (list); <br /> www.pca,state.mn.us • 651•296•6300 • 800•657-3864 • TTY b51-Z82-5332 or 800�657•3864 . i <br /> wq•wwists4-31 . 1/24112 <br /> Availabte in alternative formats <br /> Pugelof3 <br />