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� Minnesota Pollution Compliance Inspection Form <br /> - Control Agency <br /> 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems <br /> St.Paul,MN 55155-4194 �$$T$� <br /> Doc Type:Compliance and Enlorcement <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(mm/dd/yyyy): 3/17/14 <br /> � Compliant- Certificate of Compliance ❑ Noncompliant- Notice of Noncompliance <br /> (Valid for 3 years from 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 and safety <br /> ❑ Other Compliance Conditions (Compliance Component#3)-Imminent threat to public health and safety <br /> ❑ Tank Integrity (Compliance Component #2)-Failing to protect groundwafer <br /> ❑ Other Compliance Conditions (Compliance Component#3)-Failing to protect groundwafer <br /> ❑ Soil Separation (Compliance Component #4)-Failing to protect groundwater <br /> ❑ Operating permit/monitoring plan requirements (Compliance Component #5)-Noncompliant <br /> Property Information Parcel ID#or Sec/Twp/Range: 33-118-23-43-0019 <br /> Property address: 2755 Copper View Dr,Orono Reason for inspection: Owner's request <br /> Property owner: Buyer—Mike Kurth Owner's phone: 262-227-4304 <br /> Owner's representative: Representative phone: 320-334-9292 <br /> Local regulatory authority: City of Orono Regulatory authority phone: 952-249-4600 <br /> Brief system description: Two 1000 g septic tanks,to a 1000 g pump tank to a mound. <br /> Comments or recommendations <br /> Certification <br /> 1 hereby certify that all the necessary information has been gathered to determine 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 /> possible abuse of the system, inadequate maintenance, or future water usage. <br /> Inspector name: Robert Polgreen Certification number: 9037 <br /> Business name: Steinbrecher Com anies License number: L2851 <br /> Inspector signature: `�'�_ � � i� ` y^-�^-�— Phone number: 763-274-0925 <br /> Necessary or Locally Required Attachments <br /> � Soil boring logs � System/As-built drawing ❑ Forms per local ordinance <br /> � Other information (list): cover <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats <br /> wq-wwists4-31 • 1/24/12 Page 1 of 3 <br />