02/22/2021 Compliance Inspection Form

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MINNESOTA POLLUTION CONTROL AGENCY Compliance N liance inspection report form �- 520 Lafayette Road North Existing Subsurface Sewage Treatment System (SSTS) St. Paul, MN 55155-4194 Doc Type: Compliance and Enforcement Instructions: Inspection results based on Minnesota Pollution Control Agency (MPGA) requirements and attached supporting documentation - additional local requirements may also apply. Further information can be found here: htt sa/www. ca.state.mn.us/sites/defaulVfiiles/w-wwists4-31a. df, Inspector must submit completed form to Local Governmental Unit (LGU) and system owner within 15 days of final determination of compliance or noncompliance. Property information Local tracking number: Parcel ID# or Sec/Twp/Range: '0411723310011 Local regulatory authority: City of Orono Property address: 2880 Fox Street, Orono Hennepin Count Owner/representative: Brian Helms Owner's phone: 612-913-6400 Brief system description: 2-1000 gallon septic tanks, 1-1000 gallon lift station and 380 Square feet Rock bed System status System status on date (mmldd/yyyy): 2/22/2021 Z Compliant - Certificate of compliance* ❑ Noncompliant- Notice of noncompliance (Valid for 3 years from report date unless evidence of An imminent threat to public health and safety (ITPHS) must be an imminent threat to public health or safety requiring upgraded, replaced, or its use discontinued within ten months of removal and abatement under section 145A.04, receipt of this notice or within a shorter period if required by subdivision 8 is discovered or a shorter time frame exists local ordinance or under section 145A.04 subdivision 8. in Local Ordinance.) *Note: Compliance indicates conformance with Minn. Systems failing to protect ground water must be upgraded, R. 7080.9500 as of system status date above and replaced, or use discontinued within the time required by local ordinance. does not guarantee future performance. Reason(s) for noncompliance (check all applicable) ❑ Impact on public health (Compliance component #1) - Imminent threat to public health and safety ❑ Tank integrity (Compliance component #2) - Failing to protect groundwater ❑ Other Compliance Conditions (Compliance component #3) - Imminent threat to public health and safety El Other Compliance Conditions (Compliance component #3) - Failing to protect groundwater ❑ System not abandoned according to Minn. R. 7080.2500 (Compliance component #3) - Failing to protect groundwater Soil separation (Compliance component #5) - Failing to protect groundwater ❑ Operating permit/monitoring plan requirements (Compliance component #4) - Noncompliant - local ordinance applies Comments or recommendations The system is sized for a 3 -bedroom house. 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. By typing my name below, I certify the above statements to be true and correct, to the best of my knowledge, and that this information can be used for the purpose of processing this form. Business name: Rusty Olson's Soil & Perc. Testing Certification number: Inspector signatures- - - — License number: 'V l (This document has been electronically signed) Phone: C-1255 810 763-498-8779 Necessary or locally required supporting documentation (must be attached) ® Soil observation logs ❑ Other information (list): https://www.pca.state.mn,us wq-wwists4-31b • 1/11/21 ❑ Locally required forms • 651-296-6300 800-657-3864 - ® Tank Integrity Assessment ❑ Operating Permit Use your preferred relay service Available in alternative formats Page 1 of 4