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Minnesota Pollution Compliance Inspection Form <br /> rte, 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(mm/dd/yyyy): 11/20/2018 <br /> ® Compliant— Certificate of Compliance r 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 /> 0 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: 0411723410003 <br /> Property address: 2650 Fox Street,Orono, MN 55391 Reason for inspection: TRANFER OF TITLE <br /> Property owner: John Klaers Owner's phone: 612-300-0085 <br /> or <br /> Owner's representative: Representative phone: <br /> Local regulatory authority: City of Orono Regulatory authority phone: <br /> (2)1300 gallon pre-cast septic tanks,(1)1300 gallon pump tank and a 10x 63 Rock bed with 24 inches <br /> Brief system description: of sand under Rockbed, _ <br /> Comments or recommendations: <br /> Tanks were pumped and inspected at an earlier date and is not part of this inspection. Pump tanks every 3 years for maintenance. <br /> Existing rockbed and a portion of the sand was removed and replaced with new distribution rock and sand. This was completed <br /> 11/2018. Septic sytem is sized for a 5 bedroom home. <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: Pemel" ' " entges Certification number: <br /> Business name: Chips eptic Se License number: 2064 <br /> Inspector signature: Phone number: 952-200-3176 <br /> Necessary or Locally Required Attachments <br /> ®Soil boring logs ®System/As-built drawing 0 Forms per local ordinance <br /> 0 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 • 3/16/12 Page 1 of 3 <br />