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' �. � a- Minnesota Pollution • • <br /> = ControlA�ency C�mpl�ance Inspect�on Form <br /> 520 Lafayette Road North Existing Subsurtace Sewage Treatroent Systems <br /> St Paui,MN 55155-419A (SSTS) <br /> Doc Type:Compliance and Enforcement <br /> Instructiona: Inspection results based on Minnesota Pollution Corrtrol Agency(MPCA) For local tracking purposes: <br /> requirements and attached forms–additional local requirements may also apply. ( I <br /> Submit completed form to Locai Unit of Government(LUG)and sysbem owner <br /> with1n 15 days � <br /> System Status <br /> System status on date(mm/dd/yyyy): 9/7/2018 <br /> � Compliant-Certificate of Compliance ❑ Noncompliant-Notice of Noncompliance <br /> (Valid for 3 years from report date, unless shorter time (See Upgrade Requir�me»ts on page 3) <br /> frame outlined in Local Ordinance.) <br /> Reason(s)for noncomplfance(check all applicable) <br /> ❑Impad on Public Health(Compliance Component #1)-Imminent thneaf fo public health and safety <br /> ❑Other Complianoe Conditions(Compliance Component#3)-Imminent threat to public health and saiety <br /> ❑Tank integrity(Complience Component #2)–Failing to protect groundwater <br /> ❑Other Compliance Conditions(Complience Componenf#3)–Failing fo protect groundwater <br /> ❑Soil Separation(Compliance Component #4)–Failing to protect groundwater <br /> ❑Operating permiUmonitoring plan requirements(Complience Component #5)–Noncompliant <br /> Property Information Parcel ID#or SecJTwp/Range: 2511823340002 <br /> Property address: 465 Spring Hill,Orono,MN Reason for inspedion: Property Transfer ` <br /> Property owner: Richard Zona _ Owner's phone: 612-309-5351 <br /> flr _. <br /> Owner's representative: _ Representative phone: <br /> Local regulatory authoriry: CiN of Orono __ Regulatory authority phone: 952-249-4600 <br /> 2-1250 septic tanks and 1-1250 gallon liit station and 630 square feet of mound rockbed. per city <br /> Brief system description: records <br /> Comments or recommenda6ons: � <br /> TBM: Bottom of the rock bed.There is 2.7 Feet of sand under the rock bed. <br /> Certification <br /> I hertsby certify that all the necessary information has baen gathered to determine the campliance status of this system.No <br /> deteimina8on of future system pedormance has been nor can be made due to unknown conditions during system conshvction, <br /> possib/e abuse of fhe system,inadequate mainfenance, or future water usage. <br /> Inspector name: JOS@ph J Olson __ Certification number: 1255 <br /> Business name: Rus Olson's Soil&Perc.Testin License number: 810 <br /> Inspector signature: Phone number: 763-498-8779 <br /> Necessary or Locally Required Attachments <br /> �Soil boring logs �System/As-built drawing ❑Fom1s per loCal ordinanCe <br /> ❑Other information(list): <br /> .—_. ,�. <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 TfY 651-282-5332 or 800-657-3864 • Available in attemative formats <br /> wq-wwists4-31 • f/24/12 Page 1 of 3 <br />