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Minnesota Pollution Compliance Inspection Form Control Agency 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems (SSTS) St.Paul,MN 55155-4194 Doc Type:Compliance and Enforcement 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/dd/yyyy): 6/15/2018 ® Compliant— Certificate of Compliance [1 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 permit/monitoring plan requirements(Compliance Component#5)—Noncompliant Property Information Parcel ID#or Sec/Twp/Range: Property address: 2140 Carrige Lane, Orono — _ Reason for inspection: sale Property owner: Helen Henson Y—_ Owner's phone: 952-923-1598 or - — Owner's representative: -- - Representative phone: Local regulatory authority: City Regulatory authority phone: -- ---- ------- Brief system description: 2_1300_2al septic tanks and a_gravity trench system Comments or recommendations: Certification I hereby certify that al/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, or futu - water usage. Inspector name: Josh Swedlund Certification number: C1659 Business name: Sewer Se Inc License number: 2502 Inspector signature: Phone number: 952-873-3292 Necessary or Lo lly 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 • 3/16/12 Page 1 of 3