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Minnesota Pollution Compliance Inspection Form <br />Control Agency <br />= Existing Subsurface Sewage Treatment Systems (SETS) <br />520 Lafayette Road North <br />SL Paul, MN 55155-4194 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. <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 (mmldd/yyyy) <br />8/12/2020 <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 <br />Parcel ID# or Sec/Twp/Range: 1011723320011 <br />Property address: 1290 French Creek Dr Orono, MN Reason for inspection: Property Transfer <br />Property owner: Jason Cuthbertson Owner's phone: <br />or <br />Owners representative: Jen Kyllonen Representative phone: 612-839-1871 <br />Local regulatory authority: City of Orono Regulatory authority phone: 952-249-4600 <br />2-1000 gallon septic tanks and a 1000 gallon pump tank. Effluent pumped to an elevated trench <br />Brief system description: systen <br />Comments or recommendations: <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: Tristan Ende _ Certification number: C9206 <br />Business name: Ende Sqptic Service <br />Inspector signature: �L„i i <br />Necessary or Locally Required Attachments <br />® Soil boring logs ® System/As-built drawing <br />❑ Other information (list): <br />License number: L2654 <br />Phone number: 763428-4489 <br />❑ Forms per local ordinance <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-wwists4-31b • 614114 Page 1 of 3 <br />