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Minnesota Pollution Compliance Inspection Form Control Agency Control Subsurface Sewage Treatment Systems (SSTS) 520 Lafayette Road North St. Paul, MN 55155-4194 Doc Type: Compliance and Enforcement Inspection results based on Minnesota Pollution Control Agency (MPGA) For local tracking purposes: requirements and attached forms — additional local requirements may also apply. Submit completed form to Local Unit of Government (LUG) and system owner within 15 days System Status System status on date (mm/ddlyyyy): 9/6/2018 ® Compliant — Certificate of Compliance ❑ Noncompliant — Notice of Noncompliance (Valid for 3 years from report date, unless shorter time (See Upgrade Requirements on page 3.) frame outlined in Local Ordinance.) Reason(s) for noncompliance (check all applicable) ❑ Impact on Public Health (Compliance Component #1) — Imminent threat to public health and safety ❑ Other Compliance Conditions (Compliance Component #3) — Imminent threat to public health and safety ❑ Tank Integrity (Compliance Component #2) — Failing to protect groundwater ❑ Other Compliance Conditions (Compliance Component #3) — Failing to protect groundwater ❑ Soil Separation (Compliance Component 114) — Failing to protect groundwater ❑ Operating permit/monitoring plan requirements (Compliance Component #5) — Noncompliant Property Information Parcel ID# or Sec/Twp/Range: 06-117-23-22-0023 Property address: 150 North Shore Dr. W Orono, MN Reason for inspection: Property T ansfer Property owner: Steve Dzubay _ _ Owner's phone: or Owner's representative: Eric Beise Representative phone: 507-696-4246 Local regulatory authority: City of Orono _ Regulatory authority phone: 952-249-4600 _ Brief system description: 2-1000 gallon septic tanks and a 1000c alion pump tank to a pressure fed mound Comments or recommendations: Mound has a 12 inch sand lift with a 10'x37.5' rockbed. Certification l 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. Inspector name: Tristan Ende_ _ _ _ Certification number: C9206 Business name: Ende Service _ -_ License number: _ L2654___ __ _ Inspector signatur Phone number: 763-428-4489 Necessary or Locally Required Attachments ® Soil boring logs ® System/As-built drawing ❑ Forms per local ordinance ❑ Other information (list):--- www.pca.state.mn.us 651-296-6300 • 800.657-3864 TTY 651-282.5332 or 800.657-3864 • Available in alternative formats wq-ww1sts4-31b • 614114 Page 1 of 3