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03/13/2015 12:21 9528733112 PAGE 01/03 <br /> R <br /> 'k- <br /> 10�m, <br /> Minnesota Pollution Compliance Inspection Form <br /> Control Agency p <br /> 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems (SSTS) <br /> 5t.Paul,MN 55ISS-4194 .Doc Type,Compliance and Enforcement <br /> Inspection results based on Minnesota Pollution Control Agency(MPCA) For local tracking purposes_ <br /> requirements and attached forms-additional local requirements may also apply. RECEIVED <br /> Submit completed form to Local Unit of Government(LUG)and system owner <br /> within 15 days NR 13 2015 <br /> System Status '0WOF090014 <br /> System status on date(mmlddlyyyy): 3/10/2015 <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 /> i] Impact on Public Health(Compliance Component#9)-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)-F=ailing 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 IO#or Sec/Twp/Range: <br /> Property address: 1145 Wyndmere Road-Orono Reason for inspection; Sale <br /> Property owner: Steve Gill _ Owner's phone: 952-258-0470 <br /> or <br /> Owner's representative: Representative phone; <br /> Local regulatory authority; City Regulatory authority phone: <br /> Brief system description: 1250&1000 septic with a 1250 pump tank-elevated split rack trench drainfield <br /> Comments or recommendations: <br /> Top drop box on one of the drainfields is broken <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: Josh Swedlund Certification number: C1659 <br /> Business name: Swedlurid'Septic Se ' e License number, 2502 <br /> r — <br /> Inspector signature: I- - Phone number; 952-873-3292 <br /> Necessary or 1-6cally Required Attachments <br /> ®Soil boring logs M SystemlAs-built drawing ® Forms per local ordinance <br /> ❑ 0thor information(list): <br /> WWw. ca.state.mn.us • 651-296.6300 - 800.657.3864 - TTY 651.282.5332 or 800-657 <br /> p 3864 Available in alternative formats <br /> wq-wwists4-31 • 3/1611.2 Page t of <br />