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Nov 30 2015 0727PM HP FaxRusty Olson 7634988290 <br />page - <br />Minnesota Pollution Compliance Inspection n Control Agency p p o Form <br />520 Lafayette Road North Existing Subsurface Sewage Treatment Systems <br />St. Paul, MN 55155.4194 (SSTs) <br />Doc Type: Compliance and Enforcement <br />Instructions: Inspection results based on Minnesota Pollution Control Agency (MPCA) For local tracking purposes: <br />requirements and attached forms — additional local requirements may also apply. <br />Submit completed form to Local Unit of Government (LUG) and system owner <br />within 15 days <br />System Status <br />System status on date (mmtddtyyyy): 11/30/2015 <br />® Compliant - Certificate of Compliance ❑ Noncompliant - Notice of Noncompliance <br />(Valid for 3 years front report date, unless shorter time (See Upgrade Requirements on page 3) <br />frame outlined in Local Ordinance <br />Reason(s) for noncompliance (check all applicable) <br />Impact on Public Health (Compliance Component #1) — Imminent threat to public health aria safety <br />❑ Other Compliance Conditions (Compliance Component #3) — imminent threat to public health and safety <br />❑ Tank Integrity (Compliance Component #t2) — Failing to protect groundwater <br />❑ Other Compliance Conditions (Compliance Component #3) — Failing to protect groundwater <br />❑ Soil Separation (Compliance Component #4) — Failing to protect groundv,,ater <br />❑ Operatirg permiUmonitoring plan requ rements (Compliance Component 45) - Noncompliant <br />Property Information Parcel ID# or Sec/TwpiRange: 2711823420004 _ <br />Property address: 1980 Slxth Ave. N, Orono tv� Reason for ins action: Pro art Transfer _ <br />p 22 Y <br />Property owner Jim Pier�ont or Owner's phone: 952-334-3D35 _ <br />Owner's representative: _ _ _ Representative phone: _ <br />Local regulatory authority City of Orono Regulatory authority phone: _952.249-A600 <br />2.1000 gallon septic tanks,1-1000 gallon lift station and 500 square feet of mound rockbed. per city` <br />Brief system description: records <br />Comments or recommendations: — — - -- — <br />Certification <br />i hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No <br />det> rminatton of future system performance has been nor can be made due to unknown conditions during system construction, <br />possible abuse of the system. inadequate maintenance, or future water usage. <br />Inspector name: Joseph J Olson Certificatior. number 1255 <br />Business name: Rust�son's Soil & Perc. Testing — _ License number 810 <br />Inspector signature: . '' — — — -- <br />- Phone number 763-498.8779 <br />Necessary or Locally Required Attachments <br />® Sod 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 <br />hvailable 1n alternative formdCS wq-wwists4-31 1/24; 12 <br />Page 1 of 3 <br />