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� 9 <br /> Minnesota Agency ng Pollution <br /> CCompliance Inspection Form <br /> Co <br /> 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems <br /> St.Paul,MN 55155-4194 (SSTS) <br /> Doc Type:Compliance and Enforcement <br /> Instructions: 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(mm/dd/yyyy): 4/21/2016 <br /> ® Compliant-Certificate of Compliance ❑ 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 /> ❑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 permitimonitoring plan requirements(Compliance Component #5)—Noncompliant <br /> Property Information Parcel ID#or Sec/Twp/Range: 04117211100017 <br /> Property address: 2600 Thoroughbred Lane.Orono,MN _ f Reason for inspection: Pro ep rty Transfer_ <br /> Property owner: Steve Hankey _ Owner's phone: 612-760-9238 <br /> or <br /> Owners representative: _ — Representative phone: <br /> Local regulatory authority: __Cibof Orono _ -_ _ Regulatory authority phone: 952-249-4600 <br /> 1-1250 and 1-1000 gallon septic tanks,/-1250 gallon lift station and 630 square feet of mound rocketed. <br /> Brief system description: per ciV records- <br /> Comments or recommendations. <br /> 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: Joseph_J Olson Certification number. 1255 <br /> Business name: RusbOlson's Soil&_Perc.Testing 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 ❑ Forms per local ordinance <br /> ❑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-wwlsts4-31 • 1124112 Poee 1 of 3 <br />