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//ac2 �K�c�debkle <br /> Minnesota Pollution Compliance Inspection Form <br /> Control Agency <br /> Existing Subsurface Sewage Treatment Systems (SSTS) <br /> �1 La'ayetti�Road Notth <br /> S; Pain,MN 4194 Doc Tyoe:Compliance and E,)forc;cmenr <br /> Inspection results based on Minnesota Pollution Control Agency(MPGA) For local tracking purposes: <br /> requirements and attached forms-additional local requirements may also apply- <br /> Submit completed form to Local Unit of Government(LUG)and system owner <br /> within 15 days <br /> System Status <br /> System status on date(mmlddlyyyy): 11/15/2017 <br /> 71 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 permitlmonitoring plan requirements(Compliance Component#5)-Noncompliant <br /> Property Information Parcel ID#or Sec/Twp/Range 0311723430002 <br /> Property address. 1925 Fox Street.Wayzata, MN Reason for inspection: c. <br /> Property owner: Jen Ostergaard Owner's phone: 763-350-7250 <br /> or <br /> Owner's representative: SAME Representative phone: <br /> Local regulatory authority: City of Orono Regulatory authority phone: 952-249-4626 <br /> (2) 1000 gallon septic tanks,(1) 1000 gallon pump tank. Above grade drainfield, a 10x50 Rock Bed <br /> Brief system description: with 12 inces of sand under the rockbed. <br /> Comments or recommendations: <br /> Tanks were pumped and certified by others. Sewage Tank Compliance Certification is attached to this document. Maintain system <br /> by pumping the tanks every 3 years. <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 constructior. <br /> possible abuse of the system, inadequate maintenance, or future water usage. <br /> Inspector name: Pernel"Chip" Hentges Certification number: <br /> Business name: `'Chips Septic Se_ es LLC 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 Availab e in after^ati,, <br /> wq-wwists4-31 • 3/16112 Fa4e t c 3 <br />