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Jul 11 13 06:44a Joseph Olson CV"-) 763-498-8290 p.2 r Minnesota Pollution Compliance Inspection Form l ControAgency Co Road North Existing Subsurface Sewage Treatment Systems Lafayette A St.Paul,MN 55155-4194 (SSTS) Doc Type.-Compliance and Enforcement Instructions: Inspection results based on Minnesota Pollution Control Agency(MPCA) For local tracking purposes: requirements and attached forms—additional local requirements may also apply. Submit completed form to Local Unit of Government(LUG)and system owner within 15 days System Status System status on date(mm/ddlyyyy): 711012013 ® Compliant-Certificate of Compliance Noncompliant-Notice of Noncompliance (Valid for 3 years from report date; unless shorter time (See Upgrade Requirements on page 3) frame outlined in Local Ordinance.) Reason(s)for noncompliance (check all applicable) ❑Impact on Public Health (Compliance Component #1)—Imminent threat to public health and safety ❑Other Compliance Conditions(Compliance Component#3)—Imminent threat to public health and safety ❑Tank Integrity(Compliance Component #2)—Failing to protect groundwater ❑Other Compliance Conditions(Compliance Component#3)—Failing to protect groundwater ❑Soil Separation (Compliance Component #4)—Failing to protect groundwater ❑Operating permitimonitoring plan requirements(Compliance Component 45)—Noncompliant Property Information Parcel ID#or Sec/Twp/Range: 3D1182332D007 Property address: 1100 Town Line Road,Orono,MN Reason for inspection: Property Transfer Property owner: Eileen M Carter Et Al Owner's phone: unknown or Owner's representative: Douglas Deakins Representative phone: 480-229-0894 Local regulatory authority: _.City of Orono Regulatory authority phone: 952-249-4600 2-1000 gallon septic tanks,1-1000 gallon lift station and 410 square feel of mound rockbed.per city Brief system description: records Comments or recommendations: Certification 1 hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No determination of future system performance has been nor can be made due to unknown conditions during system construction, possible abuse of the system,inadequate maintenance, of future water usage. Inspector name: Joseph J Olson Certification number: 1255 Business name: Rus Olscn's Soil&Pert.Testing License number: 810 Inspector signature: Phone number: 763-498-8779 Necessary or Locally Required Attachments ® Soil boring logs ® System/As-built drawing ❑ Forms per local ordinance ❑ Other information(list): www.pca.state.mn.us 651-296-6300 - 800-657-3864 TTY 651-282-5332 or 800-657-3864 - Available in alternative formats wq-wwists4-31 - 1124112 Page 1 of 3