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request.pdf https://word-view.officeapps.live.com/wv/WordViewer/request.pdf?F... <br /> �� <br /> . f�-;:�.n�sota Poi�u�i�r. � Comptiance inspectian Form <br /> �_ontroi Agenc,.� ` <br /> @�xisting Subsueface Sewage Treatment Systems (SSTS) <br /> 52Q Lafayette Roa�s t�.,rt � Q <br /> St.Paul,MN 55155-�1u�! �/' �`�' �uc 7ype Ct;rnpliance and Enforcemerrt <br /> ,lj� � C 0 <br /> � <br /> Inspection results based on Minnesoia Pollution Ccntroi,'vgency{tvlPCkj F����ca!tracking pt:rposes <br /> requirements and attached foRns—additional local requirements may also apply. <br /> Submit completed form to Local Unit of Government(LUG)and system owner <br /> within 15 days <br /> $y5tef11 StdtUS <br /> System status on�fate(mm/ddlyyyy): 10/18/2012 <br /> � Compliant— Certificate of Compliance ❑ Noncompliant— Notice of Noncompliance <br /> (Valid for 3 years fram report date. unlcss shorter time (See Upgradc Reqc�iremenls a�page 3) <br /> frame outlined in Lr�cai Ordinance.) <br /> Reason(s)for nc;ncompliance (check all applicable) <br /> ❑ Impaci on Pi�blic Health (Comp/iance Component tt 1)—ImminenC threat to public healtl�and sa(ety <br /> ❑ Other Comp'.iance Cond�tions(Compliance Cornpanent#3)—lmminent fhrsat to public health and safety <br /> ❑Tank Integri'y{Compliar�ce Component#2)—Failing to protect groi�ndwater <br /> ❑ Other Comp!ianc;e Conditions(Compliance Cornponent#3)—Faiting to protect groundwater <br /> ❑ Soil Separafion(Compliance Component#4}—Failrng to protect grounclwafer <br /> ❑ Operating permit/monitoring plan requirements (Compliance Component#5)—Noncomp/�ant <br /> Property Information Parcel ID#or SeclT'wplRange: 3111823420009 <br /> Property address: 4325 Chippewa Lane, Orono, MN 55359 Reason for inspection_ Property Transfer <br /> Property owner Stacsy Flfeli Owner's phone: <br /> _ _--- -- <br /> or <br /> Owner's representative: Representative phone: <br /> �ocal regulatory authorit••: Orono Regulatory authority phone� <br /> Brief system description: Pressurized Mound, 2-1000 Septic Tanks. and Pump Station <br /> Comments or recomm�>ndations: <br /> Certification <br /> I hereby certify that alt th,�ner,essary informa6on has been gathered to determine the compJiance status of thrs system. No <br /> detennination ot fi�ture s�stem�erformance has been r�or can be rnade clere lo unlv�own condilions dunng system constrirctian, <br /> possible ab«se of ihe sys'em, inadequate maii�tenance, or future water usage. <br /> tnspector name: Date Jenn Certification number. 3226 <br /> Business name: George'�ExcavaTing License number. L3368 <br /> Inspector signat�re;�r ' _ Phone number 612 310-7887 <br /> Necessary or Loc��ly Required Attachments <br /> ❑ Soil borirg logs � System/As-built drawing ❑ Forms per iocaf ordinance <br /> � Uther infor,mation(' ,t): City Sep:ic Systam Ir�ventory Form <br /> _- _ _ __ _ _ _ -- _ --- <br /> www.pcastate.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800 657 38b4 • Available in aitemative fonnat, <br /> .vq wtivhts4-31 • 3l 15;`11 P a ,';>: , <br /> 3 of 7 3/25/L�b13 6`:�2 PM <br />