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G%,i4 carr t)v4o <br />Minnesota Pollution Control Agency Compliance Inspection Form <br />530 Lafayette Road North <br />Stpa,d,MN55155-4194 Existing Subsurface Sewage Treatment System (SSTS) <br />Doc Type: Compliance and Enforcement <br />Inspection results based on Minnesota Pollution Control Agency (MPGA) requirements and For local tracking purposes: <br />attached forms - additional focal requirements may also apply. <br />Submit completed form to Local Unit of Government (LUG) and system owner within <br />15 days. <br />System Status <br />System status on date (mmlddlyyyy): 7/24/2018 <br />p Compliant -Certificate of Compliance ❑ Noncompliant - Notice of Noncompliance <br />(Valid for 3 years from report date, unless shorter time (See upgrade requirements on page 3) <br />frame outlined by Local Ordinance.) <br />Reasons) for noncompliance (check all applicable): <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 92) - 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 Sec/Twp/Range: <br />Property address: 3010 Somerset Lane <br />Property owner: Jill & Patrick Butler <br />or <br />Owner's representative: <br />Local regulatory authority: City of Orono <br />Brief system description: Type I Mound for 5 bedroom home <br />Comments or recommendations: <br />Certification <br />Reason for inspection: New System <br />Owner's phone: <br />Representative's phone: <br />Regulatory authority phone: <br />952-249-4600 <br />I hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No determination of the future <br />system performance has been nor can be made due to unknown conditions during system construction, possible abuse of the system, inadequate <br />maintenance, or future water usage <br />Inspector name: Roger Peitso <br />Business name: <br />Inspector signature: <br />Necessary or Locally Required Attachments <br />Certification number: C6683 <br />License number: <br />Phone number:16'Z_Z1 It <br />Soil Boring Logs ❑ SystemlAs-Built Drawings ❑ Forms Per Local Ordinance <br />Other Information (list): <br />wq-wwists4-37c - $14114 • www.pco. state. mn.us • Available in altemative f mtats • 651-286-6300 • 800-657-3864 • TTY 651-282-5332 of 130"57-3864 Paga f 03 <br />