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; � �� MinnesotaPollution Compliance Inspection Form Control Agency 520lafayette Road North Existing Subsurface Sewage Treatment Systems (SSTS) St.Paul,MN 55155-4194 Doc Type:Compliance and Enforcement InspeCtion results based on Minnesota Pollution Control Agency(MPCA) i For local tracking purposes requirements and attached forms-additional local requirements may also apply. i I Submit completed form to Local Unit of Government(LUG)and system owner within 15 days � System Status System status on date(mm/dd/yyyy): 10/22/2016 � Compliant— Certificate of Compliance ❑ Noncompliant— Notice of Noncompliance (Valid for 3 years from report date, unJess shorter time (See Upgrade Requirements on page 3.) frame outlined in Local Ordinance.) Reason�s)for noncompliance (check all applicable) ❑ Impact on Public Health (Compliance Component#1)-Imminent threat to public health and safety ❑ Other Compliance Conditions(Compliance Component#3)-lmminent threat to public health and safety ❑Tank Integrity(Compliance Component#2)-Failing fo protect groundwater ❑ Other Compliance Conditions(Compliance Component#3)-Failing to protect groundwater ❑ Soil Separation (Compliance Component#4)-Failing to protect groundwater ❑ Operating permiUmonitoring plan requirements(Compliance Component#5)-Noncompliant Property Information Parcel ID#or Sec/Twp/Range: 2611823320005 Property address: 1540 Sixth Ave N, Orono, MN 55356 Reason for inspection: ProQer�i transfer - - -- _ _- --- _ - - Property owner: Owner's phone: or --- -- -- _ -- - ___ _— _ ----- -- - _ _ _ - Owner's representative: Patty Napier Representative phone: 763-476-1188 __ --- - - Local regulatory authority: Cityof Orono _ _ _ _ _ _ _ _ _ Regulatory authority phone: _952-249-4625 Brief system description: �_1000 gallon se�tanks, (� 1000 c�allon�ump tank, and an above rade mound system. Comments or recommendations: Maintain septic system by pumping tanks every 3 years.Tanks were pumped at time of inspection. Certification 1 hereby certify that all the necessary informafion has been gathered to determine the compliance status of fhis system No determination of future system performance has been nor can be made due to unknown conditions during system consfruction, possible abuse of the system, inadequate maintenance, or future water usage. Inspector name: Pernel" ' "Hentges _ _ _ Certification number: - -- -- - -- ___- ___. __ -- — Business name: Chi Se tic Servi s LLC License number: 2064 - - --- - -_-- _ __ _ - Inspector signature: � Phone number: 952-200-3176 Necessary or Locally Required Attachments �Soil boring logs �System/As-built drawing ❑ Forms per local ordinance ❑ Other information(list): _ __ - -- - _ -- __- __ - • - - - - - - - - - - www.pca.state.mn.us • 651-296-6300 • 800-657-3864 TTY 651-282-5332 or 800-657-3864 • Available in alternative formats wq-wwists4-31 • 3/16/12 Page 1 of 3