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Minnesota Pollution Compliance Inspection Form <br /> � Control Agency r r <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 trFVL*d <br /> requirements and attached forms—additional local requirements may also apply. <br /> Submit completed form to Local Unit of Government(LUG)and system owner FEB 0 12016 <br /> within 15 days <br /> CITY OF ORONO <br /> System Status <br /> System status on date(mm/dd/yyyy): 1/19/2016 <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 permit/monitoring plan requirements (Compliance Component #5)—Noncompliant <br /> Property Information Parcel ID#or Sec/Twp/Range: 3211823340013 <br /> Property address: 3765 Watertown Road, Orono 55359 Reason for inspection: Transfer of title <br /> Property owner: David Chute Owner's phone: <br /> or <br /> Owner's representative: Greg Hahn Representative phone: 612-867-8244 <br /> Local regulatory authority: City of Orono Regulatory authority phone: <br /> Brief system description: Pre-cast Septic Tanks, and above grade drainfield. <br /> Comments or recommendations: <br /> Existing tanks were pumped by others summer of 2015. System should be pumped on a three year schedule <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: Pernel" es Certification number: <br /> Business name: Chip's Se ' b - -7-,%, License number: 2064 <br /> Inspector signature: Phone number: 952-200-3176 <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 />