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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. <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): 6/20/2018 <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 permit/monitoring plan requirements(Compliance Component #5)–Noncompliant <br /> Property Information Parcel ID#or Sec/Twp/Range: 3311823430006 <br /> Wit+ -. _ --- _----- <br /> Property address: Old Crystal Bay Road N.,Orono, MN _ Reason for inspection: -- —Property Transfer <br /> — _ <br /> Property owner: LeAnn Coe Owner's phone: 612-812-6178 <br /> or <br /> Owner's representative: _ Representative phone: <br /> Local regulatory authority: City of Orono Regulatory authority phone: 952-249-4600 <br /> Brief system description: 2-1500 and 1-1000 gallon lift station and 680 square feet of mound rockbed. per cit records <br /> Comments or recommendations: <br /> TBM: Bottom of the rock bed.There is 1.6 Feet of sand under the rock bed. <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: I Rum son's Soil&Perc.Testing License number: 810 <br /> Inspector signatur 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-wwists4-31 • 1124112 Page 1 of 3 <br />