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Nov 0714 10:47a Joseph Olson 763-498-8290 p.2 <br /> a Minnesota Pollution Compliance Inspection Form <br /> Control Agency <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. NOV 13 ?014 <br /> Submit completed form to Local Unit of Government(LUG)and system owner i <br /> within 15 days ;ITYOFOWW <br /> System Status <br /> System status on date(mm/dd/yyyy): 11/6/2014 <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 perrnitimonitoring plan requirements(Compliance Component #5)—Noncompliant <br /> Property Information Parcel ID#or SecJTwp/Range: 3211823440018 <br /> Property address: 3220 Watertown Road, Orono,MN_ Reason for inspection: Property Transfer <br /> Property owner: Beidget Wortman Owner's phone: 952-456-2010 <br /> or <br /> Owner's representative: Representative phone: <br /> Local regulatory authority: City of Orono Regulatory authority phone: 952-249-4600 <br /> 2-1300 gallon septic tanks,1-1300 gallon lift station and 630 square feet of mound rockbed.per city <br /> Brief system description: records <br /> Comments or recommendations: <br /> The trees on the existing mound system must be removed. <br /> Certification <br /> I hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No <br /> determinafion 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: Rusty Olson's Soil&Pere.Testing License number_ 810 <br /> Inspector signature: ���-� '� Phone number. 763498-8779 <br /> Necessary or Locally Required Attachments <br /> E Soil boring logs Z 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 651-2a2-5332 or 800-657-3864 • Available in alternative formats <br /> wq-wwists4-31 • 1124112 Poge 1 of 3 <br />