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MINNESOTA POLLUTION inspection re <br />CONTROL AGENCY P p p Compliance ins ort form <br />1 <br />520 Lafayette Road North Existing Subsurface Sewage Treatment System (SSTS) <br />SL PaUI, MN 55155-4194 Doc Type: Compliance and Enforcement <br />Instructions: Inspection results based on Minnesota Pollution Control Agency (MPGA) requirements and attached supporting <br />documentation — additional local requirements may also apply. Further information can be found here: <br />https://www.pca.state mn us/sites/default/files/wa-wwists4-31a pdf. <br />Inspector must submit completed form to Local Governmental Unit (I -GU) and system owner within 15 days of final <br />determination of compliance or noncompliance. <br />Property information Local tracking number <br />Parcel ID# or SecfTwp/Range: 3011823310005 Local regulatory authority: City of Orono <br />Property address: 4545 Spruce Way Maple Plain, MN <br />Owner/representative: Jane Slaughter Owner's phone: _612-743-5669 <br />Brief system description: 2-1000 gallon septic tanks and a 1000 gallon pump tank to mound system. _ <br />System status <br />System status on date (mm/dd/yyyy): <br />❑ Compliant — Certificate of compliance* ® Noncompliant — Notice of noncompliance <br />(Valid for 3 years from report date unless evidence of <br />an imminent threat to public health or safety requiring <br />removal and abatement under section 145A.04, <br />subdivision 8 is discovered or a shorter time frame exists <br />in Local Ordinance.) <br />*Note: Compliance indicates conformance with Minn. <br />R. 7080.1500 as of system status date above and <br />does not guarantee future performance. <br />Reason(s) for noncompliance (check all applicable) <br />An imminent threat to public health and safety (ITPNS) must be <br />upgraded, replaced, or its use discontinued within ten months of <br />receipt of this notice or within a shorter period if required by <br />local ordinance or under section 145A.04 subdivision 8. <br />Systems failing to protect ground water must be upgraded, <br />replaced, or use discontinued within the time required by local <br />ordinance. <br />❑ Impact on public health (Compliance component #1) — Imminent threat to public health and safety <br />® Tank integrity (Compliance component #2) — Failing to protect groundwater <br />❑ Other Compliance Conditions (Compliance component #3) — Imminent threat to public health and safety <br />❑ Other Compliance Conditions (Compliance component #3) — Failing to protect groundwater <br />❑ System not abandoned according to Minn. R. 7080.2500 (Compliance component #3) — Failing to protect groundwater <br />❑ Soil separation (Compliance component #5) — Failing to protect groundwater <br />❑ Operating permit/monitoring plan requirements (Compliance component #4) — Noncompliant - local ordinance applies <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, possible <br />abuse of the system, inadequate maintenance, or future water usage. <br />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 <br />can be used for the purpose of processing this form. <br />Business name: Ende Septic Service Certification number: C9206 <br />Inspector signature: Tristan Ende 7 T_ License number: L2654 <br />(This document has bee el teKrro ' !ty signed) Phone: 763-428-4489 <br />Necessary or locally required supporting documentation (must be attached► <br />LI boil observation logs <br />❑ Other information (list): <br />https://www.pca.state.mn.us <br />wq-wwists4-31b • 1/11/11 <br />❑ Locally required forms <br />651-296-6300 800-657_3864 <br />® Tank Integrity Assessment <br />Use your preferred relay service <br />❑ Operating Permit <br />• Available in alternative formats <br />Page 1 of 4 <br />