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Apr 29 14 10:57a Joseph Olson 763-498-8290 p.2 <br /> Minnesota Pot(ution �ompliance Inspection Form <br /> Cantrol Agency <br /> 520LafayetteRoadNorth Existing Subsarface Sewage Treatrnent Systems <br /> St.Paul,MN 55155-4194 (SSTS) <br /> Doc 7ype:Carrrpliance and Enlwcement <br /> tnstructions: Inspectian resufls 6ased on Minnesota Pollution Cor�trol Agency(MPCA) i �or local trackir�g purposes� I� <br /> requirements and attached forms--additional local requirements may also apply. I i <br /> Submit completed form to Local Unit of Govemment(LUG)and system qwner I <br /> within 1S days I� I� <br /> $y5t(?ITl $td�US <br /> System status on date(mmlddlyyyy�: ?1312014 <br /> � Compliant-Certificate of Compliance ❑ Noncompliant- Notice of Noncompliance <br /> (Valid for 3 years from r�eport date, un/ess shorter time (See Upgrade Requrrements an page 3) <br /> frame outlined in Loca!Ordinance.) <br /> i2eason(s)for noocompliance(check al/applicable) <br /> ❑ Impact on Public Health(Compliance Component #1)—lmminent threat to pubfic health and safefy <br /> ❑ Other Compliance Conditions(CompJiance Component#3)—Immrnent threat to public health and safety <br /> ❑Tank Integrity(Comp/iance Component #2)—Failing to protect groundwater <br /> ❑Other Compliance Conditions(Comp(iance Componenk#3)—Failirrg to protect graundwater <br /> ❑Soi1 Separation{Compliance Component #4)—Faifing to protect groundwater <br /> ❑Operating permiUmonitoring plan requirements(Compliance Component #5)—Noncomplianf <br /> Property Information Parcel ED#or Sec/Twp/Range: 03-117-23-24-0014 <br /> _. <br /> Property address: 2010 Colin Drive, Orono,iNN �__ Reason for inspectiorr Property Transfer <br /> -- . <br /> Property owner: Peggy Searles ___ Owner's phone: 612-840-4752 <br /> or <br /> Owne�s representative: Representative phone: <br /> Local regufaiory authority: Ci of Orono_ _ Regulatory authority phone: 952-249-4600 <br /> 2-1000 gallon septic tanks,l-100�gallon lift station and 410 square feet of mound rockbed. per city <br /> Brief systerrT description: records <br /> Comments or recommendations: T^^ <br /> Certification <br /> !her�by certlfy that all the necessary intormabon has been gafhered to defermine rhe compfiance sfatus of this system. IVo <br /> deteanination of future system perfonnance has been nor can be made due fo unknown conditions during sysfem constructron, <br /> possible a6use of the system,inadequate mainfenance, or firture water usage. <br /> Inspector name: Joseph J Olson _ __ Certification number: 1255 <br /> Business r�ame: Rus Olson's Soil& Perc.Tesiin Lice�sa number: 610 <br /> Inspector signature: �__ _ _ _ Phone number: 763-498-8779 <br /> Necessary or Locally Required Attachrnents <br /> �Soil boring logs � Systern/As-built drawing ❑Forms per local ordinanoe <br /> �Other information(list} <br /> www.pca.state.mn.us • 651-246-6300 • 800•657-3864 • TTY 651-282-5332 or 800-657-3864 • Availab€e in a[temative formats <br /> wq•wwists4-31 • 1/24/12 Page 1 of 3 <br />