Laserfiche WebLink
Minnesata Poilution Compliance Inspection Form <br /> � Controi Agency <br /> 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems <br /> St.Paui,MId 55155-4194 ($ST$� <br /> Doc�ype:Compliance and Enfor�ement <br /> Instructions: Inspection resuks based on Minnesota Pollution Corrtrol Agency(MPCA) For locai tracking purposes: I <br /> requirements and attached forms—additional local requirements may also apply. � <br /> Submit completed form to Local Unit of Govemment(LUG)and system owner <br /> within 15 days � <br /> System Status <br /> System status on date(mmldd/yyyy): 9/17/2014 <br /> � Compliant-Certificate of Compliance ❑ Noncompliant- Notice of Noncompliance <br /> (Va1id for 3 years from report date, unless sho►ter time (See Upgrade Requirements on page 3) <br /> frame outlined in Local Ordinance.) <br /> Reason(s)for noncompliance (check aU applicab/e) <br /> ❑ Impact on Pubtic 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 Integnty(Compliance Component #2}—Failing to protect groundwater <br /> ❑Other Compliance Conditions(Compliance Component#3}—�ailing to protect groundwater <br /> ❑ Soil Separation(Compliance Component #4)—Failing to protect groundwater <br /> ❑ Operating permiUmonitoring plan requirements(Compliance Component #5)—Noncompliant <br /> Property Information Parcel ID#or Seclfwp/Range: Q611723210005 <br /> Property address: 4565 Ba�side Road,Orono,_MN ____ Reason for inspection: Property Transfer__ <br /> Property owner: _Peter Rennebohm _ _ Owner's phone: <br /> or <br /> Owner's representative: ____ _ Representative phone: <br /> Local regulatory authority: Ci of Orono_ ______ Regulatory authority phone: 952-249-4600 <br /> Brief system description: 2-1000 and 1-1000 gallon lift station and 410 square feet of mound rockbed. per ciry records <br /> Comments or recommendations: <br /> Certification <br /> I hereby certify that all the necessary informafion has been gafhered fa defermine 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 /> possibte abuse of the system, inadequate maintenance, or future water usage. <br /> Inspector name: Joseph J Olson Certification number: 1255 <br /> Business name: Rust Olson's Soil&Perc.Testing License number: 810 <br /> Inspector signature: ----•• ----.�__� ___ _ Phone number: _ 763-498-8779 <br /> Necessary or Loca(ly Required Attachments <br /> � Soil boring logs ❑ System/As-built drawing ❑ Forms per local ordinance <br /> ❑ Other information (list): <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in atternative formats <br /> wq-wwists4-31 • t/24/12 Pvge t of 3 <br />