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Jan 28 14 05:34p Joseph Olson 763-498-8290 p.2 <br /> Minnesata Potfution �prp liance Inspect�on Form <br /> Eontro! Agency <br /> 520 Lafayette Road North Existing S bswrface Sewage Treatment Systems <br /> st.�aui,MN 5 51 5 5-41 9q (SSTS) <br /> Doc Type:Compliance and Enfor�ement <br /> Instructions: Inspection resuEfs based on Minnesota Pollution Control Agen (MPCA} Far(ocal tradcing purposes: <br /> requirements and attached forms—additional local requiremerrts may also a ly. <br /> Submit completed form to Local Unit of Govemment(LUG)and syste owner <br /> within 95 days <br /> System Status <br /> System stattts on date(mmlddlyyyy): 12/i812U13 <br /> � Compliant—Certificate of Camplia�ce ❑ f�oncompliant—Notice of No�compliar�ce <br /> {Valid for 3 years from reporf date, unless shorter bine (See Upgrade Requiremenfs on page 3J <br /> frame oudined in Loca!Oro'inance.J <br /> Reaso�(s)for noncompliance{check all applicable) <br /> ❑Jmpact on Public Health{Compliance Component #7)—Immin t threat to pubkc heafffi and safety <br /> ❑Oiher Compliance Conditions(Compliance Componenf#3)—1 inent threat to public healfh and safety <br /> ❑Tank Jntegrity(Complian�e Camponent #2)—Farling to protect roundwat�r <br /> ❑Other Cor�pliance Conditions(Compliance Cornponenf�t3J—F i/ing fo proteet grnundwater <br /> ❑Soil Separation(Compliance Component #4)—Fai6ng to prr�fe groundwater <br /> ❑ Operating permitJm�nitoring plan requirements(Compliance Co ponent #5)—Noncomplianf <br /> Property Inform�tion Parcel ID#ar Se wplRange: 0611723130001 <br /> Property address: 4245 Bayside Road,Orono AAN ^ Reason for inspecE+on: Property Transfar <br /> Property owner: � Owners phone: <br /> or ---- <br /> Owner's represerrtative: Catherine Wersat Representative phone: 612-597-&S61 <br /> �ocal regulatory authority: City of Orono __ Regulabory authflnty phone: 952-2A9-4600 <br /> 2-1 Q00 galiot�septic tanks,1-1000 ga[lan lift sta n and fi30 square feet of mound rockbed.per ciry <br /> Brief sys3em description: records <br /> Commenis or recommendations: <br /> Certificatton <br /> J heneby cert�fy that al!the necessary informafion has been gafhered to dete ine the compliance sfalus of thfs system.No <br /> deterrnination of futu�system perfarnrance has been nor can be made due unknawrt corrditions during system constructron, <br /> possible abuse ofthe system,inadequa2e maintenance, arfuture wat�rusa . <br /> Inspector name: Joseph J Olson Certifica5on number: i 255 <br /> — - _.. _ <br /> Business name: Rus son's Soil 8�Perc.7esiing License ne�mber: 810 <br /> InspecEor sigRatcare: ��----�'"'�� � Phone number. T63-498-8779 <br /> Necessary or Locally Required Attachments <br /> �Soil boring togs �S�rstem/As-built dtawEng ❑ F rms per local ordinance <br /> 0�ther information pist}: <br /> www.pcastate.m�.us - 551-296-630� • 8D0-657-3864 • T�'Y 651-28 -5332 or 800-657-3864 • Available in alCemative formats <br /> wq•wwists4-3i • r�24rr2 ?age 1 of 3 <br />