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V Minnesota Pollution Control Agency Compliance Inspection Form 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems (SSTS) St.Patti,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): 8/12/2017 ® Compliant— Certificate of Compliance ❑ 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: 4645 Bayside Rd Orono MN Reason for inspection: property transfer Property owner: Eric Sims Owner's phone: or Owner's representative: Representative phone: Local regulatory authority: City of Orono Regulatory authority phone: Brief system description: 2-1000gal septic tanks 1000 al pump tank mound treatment with 10ftX63ft rockbed Comments or recommendations: Certification I hereby certify that all 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 future water usage. Inspector name: Andrew Kleindl Certification number: 7927 Business name: Jim's Exca atin LLC License number: 2926 Inspector signature: L ' ��ti" Q.(.L ' Phone number: 952-442-9282 Necessary or Locally 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-wY4sts4-31b • 614114 Poge i of 3