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Nov 11 2016 09:08AM HP FaxRusty Olson 7634988290 page 2 <br /> Minnesota Poilution Cornpliance Inst�e�tion Form <br /> Control Agency N <br /> SZOLafayetteRoadNorth Existing Subsurfaee Sewage Treatment Systems <br /> SL Peul,MN 55155-4194 �$$�� <br /> �oc Type;Compliance and E'nforcement <br /> Inatructfons: Inspection results based on Minnesota Pollution Control Agency(MPCA) � For local track' <br /> requiremerrts and attached forms—additional local requirementa may also apply. i ���E D <br /> Submlt completed form to Local Unit of Government(LUG)and systern owner NQV � 4 ���6 <br /> within't5 days <br /> � <br /> System Status <br /> c�rr oF oRon,o <br /> System status on date(mrnlddlyyy ): 10l27116 <br /> �Compliant-Certificate o Complianc ❑ Noncompliant- Notice of Noncompliance <br /> (Valid fvr 3 years from rieport daf unfess shorfer ti (See Upgrade Requirements on page 3) <br /> frame outlined in Zoca!Ordinance <br /> Reason(s)for noncompliance (che plicable) <br /> ❑Impact on Public Health (Compliance Component #1 J-Imminent th�eal to public health and safety <br /> ❑ Other Compliance Conditans(Compliance Compa�ent#3)-Imminenf thraat to public healfh and safety <br /> ❑Tank Integrity(Compliance Componenf #2)-Faif;ng fa protect groundwater <br /> ❑Other Compliance Conditions(ComplianCe Component#3)-Failing to proteCt groundwater <br /> ❑Soil Separation (Compllance Camponent #4)-Fai►ing ro protect groundwater <br /> ❑Operating permit/monitoring plan requirements(Compliance Comporrent #5)-Noncompfiant <br /> Property Information ParCel ID#or Sec/Twp/Range: 0411 72321 001 1 <br /> Property address: 2990 Somerset Lane Orona, MN Reason fnr inspedion: Pro ert Transfer <br /> Property owner: Michael Bund Owner's phane: <br /> or <br /> Owner's representative: Chelsea Shaw Representative phone: 505-809-4503 <br /> Local regulatory auihority: City of Orono Regulatory authority phone: 952-249-4600 <br /> 2-1300 gallon septic tanks,l-1300 gallon lift station and 830 square feet of mound rockbed, per city <br /> Brief system description� records . <br /> Commenls or recornmendations: <br /> Certification <br /> I hereby cert!!y thaf al!the necessary infom�a6on has been gathered to dete�mine tha eompliance status of bhis system.No <br /> detennination of/uture system performance has been nor can be made due to unknown conditions durrr►g system conshuction, <br /> possible abuse of the sysfem,Inadequete mainAsnance, or futum water usage. <br /> Inspector name: J h J Olson Ceriification number: 1255 <br /> Business name: Rus n's Soil&Perc.Testin License number: 810 <br /> Inspector signature: Phone number: 763-498-87TS <br /> Necessary or ocally Required Attachments <br /> � Soil boring logs �SystemfAs-built drawing ❑ Forrns per local ordinance <br /> ❑ Other iriformation pist): <br /> www.pca.state.mn.us • 651-Z96-6300 • 800•657-3864 • TTY651-282-5332or8U0-657-3$64 • Availableinaitematfveformats <br /> wq-wwfsts4-3i . 1I24/12 Pc�e 1 oj 3 <br />