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Oct 21 14 07:05p Joseph Olson 763-498-8290 p.2 <br /> �innesota �ol�utian Compliance Inspection Form <br /> Control Agency <br /> 52p LaFayette Road t�orth Ex�sting Subsurface Sewage Treatment Systems <br /> St.Paul,MN 55155-�194 �SSTS� <br /> Doc Type:Complrance and Enforcement <br /> RE��le��'�, <br /> Instructions: Inspeclion results based on Minnesota Poffution Corrtrol Agency(MPCA} �or lor:al tracking purposes: <br /> requirements and attached forms—additional loql reGuiremerrts may also apply. �CT 2 2 Z��4 <br /> Submit completed form to Lacal Unit of Government{LUG}and systern owner <br /> within 15 days <br /> System 5tatus <br /> System stateis on date(mm/dd/yyyy�: 911712014 <br /> � Compliant- Certificate of Compiiance ❑ Noncompliant-Notice af Noncornpliance <br /> (Valid for 3 years fram report date,unless shorter�'me (See Upgrade Requr�men�s on page 3) <br /> frame outlined in Locai Qrrlinance.) <br /> Reason(s)for noncompliance (check alf applicable) <br /> ❑ Impact on Public Health(Compliance Component #i)—lmminent threaf to pubJic health and safety <br /> ❑ Other Compliance Conditions(Compliance Component#3)—Jmminent threat to pubfic healfh and safety <br /> ❑Tank Integrity(Compliance Component #2)—Failing to proteet graundwater <br /> �Other Compiiance Conditions(Comp/iance Component#3)—�ailing to protect groundwater <br /> ❑Soil Separation (Compliance Component #4)—Farling to profect groundwater <br /> (]Operating permit/monitoring p�an requirements(Compliance Component #5)—/Uoncomplianf <br /> Aroperty Infarrnation Parcel ID#or SecJTwplRa�ge: 0$11723210005 <br /> Properiy address: 4565 Bayside Road,Orono, MN Reason for inspedion: Property Trans�er <br /> Property owner: Peter Rennebohm Owner's phone: <br /> or - <br /> Owner's representative: Representative phone: <br /> Local regulatory authority: Gity of Orono Regulatory authority phone: 952-249-4600 <br /> Brief system description_ 2-1000 and 1-1000 gallon lift station and 4'f0 square feet of mound rockbed. per city r�eoords <br /> Comrnents ar recomrnendations� <br /> -- <br /> Certification <br /> !he�by certfy that alI tf�e necessary irrformafion has been gathered tv determrne the compliance status of this system.No <br /> detenninatioR of firture system performance has been nor can 6e made due to unknown cortdi&ons dunng system construction, <br /> possible abuse of the system, inadequate maintena�ce; or future wafer usage. <br /> Inspector narne: Joseph J Olson _ Certification number: 1255 <br /> Business name: Rus Ofson's Soil&Perc.Testin License number: 810 <br /> Inspector signature: Phone number: 763-498-8779 <br /> Necessary or Locally Required Attachments <br /> � Soil bo�ing logs ❑ SystemlAs-builE drawing ;]Forms per local ordinance <br /> ❑ Other information{lisi): <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • T7Y 651-282-5332 or 800-657-3864 • kvaiEabte in alterna[ive formats <br /> wq-mvists4-31 • i1241 i2 <br /> Paqe i of 3 <br />