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Minnesota Pollution Control Agency Compliance Inspection Form 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems St. Paul, NIN 55155-4194 (SSTS) Doc Type: Compliance and Enfot ., men1 Instructions: 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 (mmlddlyyyy): 712012018 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 #4) -Failing to protect groundwater ❑ Operating permit/monitoring plan requirements (Compliance Component #5) - Noncompliant Property Information Parcel ID# or SeclTwplRange: 0411723240002 Property address: 225 Old Crystal Bay Road S., Orono, MN Reason for inspection: New Construction Property owner: Jason Pitts _ - - _ - — - Owner's phone: or Owner's representative: - Gordon James _ _ Representative phone: 763-479-3117 Local regulatory authority: _ City of_O_rono _ _ - Regulatory authority phone: 952-249-4600 Approximately 1-1000, 1-1000 gallon septic tanks,1-1000 gallon lift station and 625 square feet of Brief system description: mound rockbed. Comments or recommendations: TBM: Top of S.W. Corner iron EL -996.4. The existing system has 1.3 feet of sand. The existing tanks are to be abandoned. 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. Inspector name: Josue J Olson Certification number: 1255 Business name: Rust Ol on's Soil &_Per_c. Testis - _ - — License number: $10 Inspector signature: Phone number: 763-498-8779 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-wwists4-31 • 1124112 Page1of3