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Minnesota Pollution <br />Compliance lance Inspection Form <br />Control Agency <br />520 Lafayette Road North <br />Existing Subsurface Sewage Treatment Systems <br />St. Paul, MN 55155-4194 <br />(SETS) <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 16 days <br />System Status <br />System status on date (mm/dd/yyyy): 11/3/2020 <br />❑ Compliant — Certificate of Compliance Z 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 Parcel ID# or Sec/Twp/Range: 3011823330005 <br />Property address: _4680 Creekwood Trail Orono, MN — Reason for inspection: Property Transfer <br />Property owner: _ Dale Olsen Owner's phone: _ 972-768-4488 <br />or <br />Owner's representative: Representative phone: <br />Local regulatory authority: City of Orono _ Regulatory authority phone: 952-249-4600 <br />Approximately 2-1000 gallon septic tanks, 1-1250 gallon lift station and approximately 630 square feet <br />Brief system description: of mound rockbed. <br />Comments or recommendations: <br />TBM: Top of the garage concrete slab. The rock bed has 1.0 feet of sand under it on the East side and 2.1 on the West side. The <br />rock bed meets the 2.55 foot separation requirements. <br />The existing tanks are rotting and need to be replaced. Once the tanks are replaced the system will be compliant. <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 _ Certification number: 1255 <br />Business name: -Rusty OI on's Soil & Perc. Testing License number 810 <br />Inspector signature Phone number: 763-498-8779 <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.u5 • 651-296.6300 • 800.657.3864 TTY 651-282-5332 or 800.657-3864 • Available in alternative formats <br />wq-wwists4-31 • 1124112 Page i of 3 <br />