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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) 1 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 (mmlddlyyyy): 7/5/2020 <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 />0 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 #5) — Noncompliant <br />Property Information Parcel ID# or SecfTwpiRange: 0411723410011 <br />Property address: 2400 Fox Street, Orono, MN Reason for inspection: Property Transfer <br />Property owner: Julie Lindbloom Owner's phone: <br />or <br />Owner's representative: Jeffery Dewing Representative phone: 952-471-2279 <br />Local regulatory authority: City of Orono Regulatory authority phone: 952-249-4600 <br />Brief system description: <br />2-1300 gallon septic tanks and 1-1300 gallon lift station and 620 square feet of mound rockbed. per city <br />records <br />Comments or recommendations: <br />TBM: Top of the garage concrete slab. There is 1.0 Feet of sand under the rock bed. <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 <br />Business name: —Rusty OIs 's Soil & Perc. Testing <br />Inspector signature: <br />Necessary or Locally Required Attachments <br />E Soil boring logs <br />❑ Other information (list): <br />Certification number: 1255 <br />License number: 810 <br />Phone number: 763-498-8779 <br />® System/As-built drawing ❑ Forms per local ordinance <br />www.pca.state.mn.us 651-246.6300 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 />