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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 (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 (mm/dd/yyyy): 2/512021 <br />Compliant - Certificate of Compliance <br />(Valid for 3 years from report date, unless shorter time <br />frame outlined in Local Ordinance.) <br />Reason(s) for noncompliance (check all applicable) <br />El Noncompliant - Notice of Noncompliance <br />(See Upgrade Requirements on page 3) <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 95) — Noncompliant <br />Property Information <br />Property address: . 40 Truffula Trai, Orono, MN <br />Property owner: Luis &b Veronica Acosta <br />or <br />Owner's representative: Shane Joseph <br />Local regulatory authority: City of Orono <br />Parcel ID# or Sec/Twp/Range: 3311823440035 <br />Reason for inspection: Property Transfer <br />Owner's phone: 952-249-0687 <br />Representative phone: 612-250-8399 <br />Regulatory authority phone: 952-249-4600 <br />1-1250 and 1-1000 gallon septic tanks and 1-1250 gallon lift station and 680 square feet of mound <br />Brief system description: rockbed. per city records <br />Comments or recommendations: <br />TBM: Top of the lift station manhole cover. There is 1.2 Feet of sand under the North side of rock bed. There is 2.2 Feet of sand <br />under the South side of rock bed. <br />Certification <br />1 hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No <br />detennination 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 OIs n's Soil & Perc. Testing <br />Certification number: 1255 <br />License number: <br />810 <br />Inspector signature: Phone number: 763-498-8779 <br />Necessary or Locally Required Attachments <br />® Soil boring logs Z System/As-built drawing El Forms per local ordinance <br />❑ Other information (list): <br />www.pca.state.mn.us - 651.296-6300 <br />wq-wwists4-31 - 1124112 <br />804.657-3864 <br />• TTY 651-282.5332 or 800-657-3864 - Available in alternative formats <br />Page 1 of 3 <br />