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Minnesota Pollution Compliance Inspection Form <br />Control Agency <br />520 Lafayette Road North Existing Subsurface Sewage Treatment Systems <br />St. Paul, MN 55155-4194 (SSTS) <br />Doc Type: Compliance and Enforcement <br />Instructions: 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 (mm/ddlyyyy): 12/1812020 <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 />Property address: 395 Sussex Lane, Orono, MN <br />Property owner: Jon Campbell <br />or <br />Owner's representative: <br />Parcel ID# or Sec/Twp/Range: 0411723240007 <br />Reason for inspection: PropeTransfer <br />Owner's phone: 612-849-3232 <br />Representative phone: <br />Local regulatory authority: City of Orono Regulatory authority phone: 952-249-4600 <br />Approximately 2-1300 gallon septic tanks,11-1300 gallon lift station and 750 square feet of mound <br />Brief system description: rockbed. Per city records <br />Comments or recommendations: <br />TBM: Top of the existing lift station manhole cover. The system has 1.3 feet of sand. There is 10 inches of rock. <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: Joseph J Olson <br />Business name: Rust 0 on's Soil & Perc. Testing <br />Inspector signature: <br />r <br />Necessary or Locally Required Attachments <br />Certification number: 1255 <br />License number: 810 <br />Phone number: 763-498-8779 <br />® Soil boring logs Z System/As-built drawing ❑ Forms per local ordinance <br />❑ Other information (list): <br />www.pca.state.mn.us <br />wq-wwists4-31 • 1124142 <br />651-296-6300 800-657.3864 <br />TTY 651-282-5332 or 800-657-3864 . Available in alternative formats <br />Page 1 of 3 <br />