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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(mmidd/yyyy): 4/25/2018 <br /> ® Compliant— Certificate of Compliance E 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 /> El 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: <br /> Property address: 1235 Lyman Ave, Orono Reason for inspection: sale <br /> Property owner: Paul Pesek Owner's phone: 952-476-2300 <br /> or ---- -- -- — <br /> Owner's representative: — _ _ Representative phone: <br /> Local regulatory authority: City of Orono Regulatory authority phone: <br /> Brief system description: 2-1000 septics& 1000 gal pump tank with a 3 bedroom mound system <br /> Comments or recommendations: ---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: Josh Swed . d Certification number: C1659 <br /> Business name: Sewer S fifes In License number: 2502 <br /> Inspector signature: .� ' Phone number: 952-873-3292 <br /> Necessary or L. ally Required Attachments <br /> ® Soil boring logs ® System/As-built drawing ® 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 <br />