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<br /> '��' ���` � Mi�nesata Pollution
<br /> � � � �� �� Compliance Inspe�tion Form
<br /> �"�-'=�`- C trol A e
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<br /> `�'= �� 9 ��y" Existing Subsurtace Sewage Tr�tmelrt Systems (SSTS)
<br /> 520 Lafayette Road North
<br /> St Paul,MN 55155-4194 ' Doc Type:Compliance and Er►fi�rCement
<br /> Iri�sp�i:tion results bssed on Minnesote Pollution Control Agency(MPCA) For local tracking purposes:
<br /> requirements and attached forms-additional local requirements mey also appry.
<br /> Submit completed form to Local llnit of Gov�mment(LUG)and system owner
<br /> within 15 d�ys ��
<br /> System Status �
<br /> Sysbem status on date(mmldd/yyyy): 12/9/2012 �
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<br /> � Compliant-Certificate of Compliar�ce ❑ Noncompliant- Notice of Noncomplia�ce
<br /> (Valid for 3 years from report dat�, unless shorter time (See Upgrede Requi�ments on page 3.)
<br /> fr�me oudined in Local Ortirnence.)
<br /> -,Reason(s)for noncompliance(check all applica6le)
<br /> � .�- � . - ,
<br /> �'�I�p�ctbFi'I�E3b�lc9l��i��(�omplia�csComponent 1)'=��Jl�ntti►ie8t'to"public' ��� I� r �w�
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<br /> ., � �� ,; ���� :
<br /> - p'Other�d�mpliarla��onditions(Com_Iiance Com on � ��r
<br /> ent#3) ,=Imminent thieat to public, ealth and safety
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<br /> . ���nk�R�9��Y(�m�(iance Componerit�#2)-�Failirig to pibtectgroundwater _. ,.. `.➢ '.. � ��' '. .
<br /> �Other Complia�c��onditions(Comp/iance Componenf#3)-Failing fo proiect groufidwater�� �;�-� ��
<br /> ❑Soil Separation(Complience Component#4)-Failing fo protect groundwater
<br /> ❑Operating permit/monRoring plan requirements(Compliance Componerrt#5)-Noncompliant ___„_ _. .
<br /> 6F1S�!'�f G, ., . t ., �'-, .,�,,;' �ri�,h, .•i.� , " � � "dl• �� ,..� . . , . ...� .
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<br /> ���PertY �nformatian;,a �.a � , . � � , i Parcel ID#or 9eclTwp/Range: �I���g"Z3^/2�00/Z
<br /> P�r� �
<br /> ��'�y aaar�ss: 4225 County Road 6 Orono� MN.55356 Reason ior inspec�ion:�--Prnperr�Transfer ,
<br /> Property owner. Owner's phone:
<br /> ��rsar����►�������, ��.� ���-�
<br /> -4�aaer'-s representative;-- Mif►nas�cta Home Team:Com Attn: Kyle�VUhite Representative{�hene����-�852)•2,ZFrT/31�.,��-. -. -
<br /> Local i�cj�llatory autho�ity: �fa Ci of�Oroii�aY)� Regulatory authority phone: (95�249-4600
<br /> �� �o�t�comm�endeYl�Cfklst�- .' , , , y d Pressure Mound r s
<br /> B' sc�s,tem description:�Se tic Tani6(/bOa Pum Chamber an
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<br /> 1 hereby cer�if�`tNat�l1 Che neeessary infom►a6on hes bee►�gathered Eo deteimine the compliance status of this system. No
<br /> determrnation of futu�,$y�tem, p�iwrmance has b,een nor cen;�e mac�e duQ to unknown cardi�on�,dur�ng sysi�em construction,
<br /> possible abuse of the s�!sfem,in�,dgquate maintenence, or future waf�r usepe.
<br /> lnspector name; ��h�,�a.s„�,,Klan�nik , � Certfication number,;,,�R,a945
<br /> -•B�siAess�r�arpe_. .AdvaFlead-� _ .-� ._ License number:. _��666 .-..___ . :.. ,., ..
<br /> lnspector signature: v� • ' Phone number: (612)232�737
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<br /> Ne'��s�ry'o'r"Lb�ailji'Required Attachmerpt5 '�� ''� .- � p ���---`� ` '' -
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<br /> ��1�IeSoil borin lo s- ;r, ,{ .
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<br /> g g — �S�ystem/As-built drawing - d Fo�ms per Iocal ordinance- -
<br /> `5�j�ei�"in�rmatioF►{list). - --- _ ._._ ___ _.._. . _ _ .----- - .._... ___ . � _ _
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