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Jan 28 2016 07:04PM HP FaxRusty Olson 7634988290 <br /> page 2 <br /> Minnesota Pollution <br /> Control Agency Compliance Inspection Form <br /> 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems <br /> St.Paul,MN 55155-4194 <br /> ($STS) <br /> Doc Type.Compl/ante and Enfomemeni <br /> Instructions: Inspection results based on Minnesota Pollution Control Agency(MPGA) j For local trad <br /> requirements and attached fomlq—additional local requirements may also apply. <br /> Submit completed fonm to Local Unit of Government(LUG)and system owner JAN 2 11116 <br /> within 15 days <br /> System Status CnyOFORON ) <br /> System status on data(mm/dd/yyyy); 1/27/2016 <br /> ® Compliant-Certificate of Compliance ❑Noncompliant-Notice of Noncompliance <br /> (Valid for 3 years from report date, unless shorter time <br /> frame outlined in Local Ordnance.) (See Upgrade Requirements on page 3) <br /> Reason(s) for noncompliance(check all applicable) <br /> ❑ Impact on Public Health(Compliance Component #1)-Imminent threatto public health and safety <br /> ❑Other Compliance Conditions(Compliance Component#3)—Imminent threat to public health and safety <br /> ❑Tank Integrity(Compliance Component #2)—Failing to protect groundwater <br /> ❑Other Compliance Conditions(Compliance Component#3)—Failing to protect 9nwndwater <br /> ❑Soil Separation (Compliance Component #4)—Failing to protect groundwater <br /> ❑Operating permit/monitoring plan requirements(Compliance Component #5)—Noncompliant <br /> Property Information Parcel DO or Sec/Twp/Range: 0¢117-23-11-0021 <br /> Property address: 2575 Thoroughbred Lane Orono,MN <br /> Reason for inspection: <br /> Property owner. Steven Sapletal Property Transfer <br /> or Owner's phone: 612-708-2556 <br /> Owner's representative: <br /> Local regulatory authority: C!Y of Orono Representative phone: <br /> 2-1300 gallon septic tanks,1-1300 lion lift stationeand 630 ory authority phone; 952-244600 <br /> Brief system description: records square fast of mound rockbed.per city <br /> Comments or recommendations: <br /> Certification <br /> I hereby c@n'yy that ail the necessary information has been gathered to determine the compliance status orchis system. No <br /> determination of future system performance has been nor can be made due to unknown conditions during system <br /> possible abuse of the system,inadequate maintenance, or future water usage. construction, <br /> Inspector name: Joseph J Olson <br /> Business name: Rust OI 's Soil&Perc.TestingCertification number: 1255 <br /> License number: 810 <br /> Inspector signature: <br /> Phone number: 763-498-8779 <br /> Necessary or Locally Zequi�redAttnhrnents <br /> ®Soil boring logs ®System/As-built drawing ❑Forms <br /> ❑Other information(list): Per local ordinance <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-wwlsts4.31 . 1124112 <br /> Page 1 of 3 <br />