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Feb 29 2016 05:06RM HP FaxRusty Olson 7634988290 page 2 <br /> Minnesota Pollution Compliance Inspection Form <br /> Control Agency <br /> S20 Ufa yette Road North Existing Subsurface Sewage Treatment Systems <br /> St.Paul,MN 55155-4194 (SETS) <br /> Doc Type:Compliance and Enforcement <br /> Instructions: Inspection results based on Minnesota Pollution Control Agency(MPCA) For ores: <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 2 9 2016 <br /> within 15 days t <br /> crrY of ORON , <br /> System Status <br /> System status on date(mm/dd/yyyy): 2125/2016 <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 #i)-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 SecfTwp/Range: 26-118-23-41-0009 <br /> Property address: 1185Wyndamere Road.,Orono MN _ Reason for inspection: Property Transfer <br /> Property owner: Gary Gronneberg Owner's phone: 612-860-5475 <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: 2-1000 and 1-1000 gallon lift station and 1500 square feet of Trench per city records <br /> Comments or recommendations: <br /> Certification <br /> 1 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: Rus on's Soil&Perc.Testing License number: 810 <br /> Inspector signature: 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 • 1/24112 Page 1 of 3 <br />