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Nov 50 2015 07:27PM HP FaxRusty Olson 7634988290 page 2 <br /> Minnesota Pollution Compliance Inspection Form <br /> Control Agenty <br /> 520 Lafayette Raad North Existing Subsurface Sewage Treatnnent Systems <br /> St.Paul,MN 55155-4194 ($$T$) <br /> Doc Type:Compliance end Enforcement <br /> instructions: Inspection results based on Minnesota Poliution Control Agency(MPCA) For local tracking purposes: <br /> requirements and attached forms—additional local requirements may also apply. II <br /> Submit Completed form to Local Unit af Government(LUG}and system owner <br /> within 1 S days i <br /> sySt@CTl StdtUS <br /> System status on date(mmlddtyyyy); 11130/2015 <br /> � Compliant- Certificate of Compliance ❑ Noncompliant-Notice of Noncompliance <br /> (Valid for 3 years from rnport date, unless sho�ter 6me (See Upgrade Requirements on page 3) <br /> frame outlined in Loca!Ordinance.J <br /> Reason(s)for noncompliance (check all applicable) <br /> ❑ Impact on Pubiic Health (Complrance Component #fJ—Irnmrnent threatfo public healfh and safety <br /> ❑Other Compliance Conditions(Compliance Component#3)—(mminent fhreat to publrc heaJth and safety <br /> ❑Tank Integrity(Compliance Component #2)—Faifing to profect groundwafer <br /> ❑Other Compliance Conditions(Compliance Component#3)—Failing to pratect groundwate� <br /> ❑Soil Separation(Compliance Component #4)—Failing to protecf groundwater <br /> ❑ Operating permit/monitoring plan requirements(Compliance Component #5)—Noncompliant <br /> Property Information Parcel ID#or Sec/Twp/Range; 2711823420004 <br /> Property address: 1980 Sixth Ave. N,Orono, MN Reason for inspection: Pro ert Transfer <br /> Property owner Jim Pierpont Owner's phone: 952-334-3D35 <br /> or — <br /> Owner's representative: Representative phone: <br /> Local regulatory authoriry: City of Orono Regulatory authority phone: 952-249-4600 <br /> 2-1000 gallon septic tanks,1-100o gallon lift station and SQO square teet of mound rockbed. per city <br /> Briet system description: records <br /> Comments or recommendations: <br /> Certification <br /> 1 hereby certify that all fhe necessary informah'on has been gathered to determine the compliance status of thrs system. No <br /> determination of future system perfoimance has been nor can be made due to unknown condifrons dunr�g system construction, <br /> possib/e abuse of the system, inadequate maintenance, or future water usage. <br /> Inspector name: Joseph J Olson Certification number: 1255 <br /> 8usiness name: R�st 0 son's Soil&Perc.Testing License number: 81Q <br /> Inspectorsignature: .' ---- Phone number, 763-498-6779 <br /> Necessary or Locally Required Attachments <br /> � Soil boring logs �Sysfem/As-built drawing ❑ Forms per local ordinance <br /> ❑Other information {list): <br /> www.pca.state.mn.us . 651-296-6300 • 800-657-38b4 • TTY 651•282-5332 or 800-657-3864 . Available in altemative formats <br /> wq-wwists4-31 • 1/14!12 Page 1 oj 3 <br />