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V <br /> � � Minnesota Pol{ution Cor�pliance lnspection Form <br /> � � Controt Agency - ��=�1� <br /> 520 WfdyetteRoad Nath Exlsting Subsu*fsce Sswi+ge T�estment Systenes (iSTS) <br /> sc.Pau�,MlV 5515�4194 Instructions on page J <br /> ParCel nurnber: FOr LocalTracldng Pu�poses: <br /> System status: �Compiiant ❑Nonoompliant <br /> (besed on all c:or►►pi/enCe leqvirer►tenls) <br /> Sum�nary�onn <br /> Property Informatiort <br /> Property ovmer name{s): Ke�th Fritze <br /> Proper{y address: 25a5 Coun ei�fe Orive,arorso MN 553b6 <br /> Ptoperty ow�net's addcess(Nc1MAeronq: <br /> County: Hennepin , Property owner phar►8: 952�7�9703 Permitt+�g authority: City of Orono <br /> Dste-system�o�s#�: f4/4'N88 Ressor+�oc� R�r Tcac�ter <br /> System Des�ription <br /> A,p�ly 2-tODD galton se�ic lanka,1-1000 Aalla'�IiR stetion snd Approximately BSO squere <br /> 8rief syatem desrxipEivn: feef of maund rodc6ed. <br /> Locel permit numbet: Number of bedrooms: 5 Design flow rate: -83 <br /> b the aysEem: <br /> tn Shoreland area? [1 Yes �No In WeAhead ProtecUon Rrea'i Q Yes (�Fio <br /> M U.S.E�vironmental ProteCtloa 5ystem serving e MinnBsota Department <br /> flgenc�+t�flR3 c�asa v lnjecr;ort vve�F�B Yes �t+lo �c Neat#(AAt1h)aic�nsed tacUtt� �7 Yes �N� <br /> CompHance Status�a05ea o�state requ�re�nenta-addic�o►,aI 1oca1 req�remerns may a�so epply.) <br /> Based o�the informaGon gatt�red and reported on att8ched iortna,the oompli�oe staEas of tlris a�stem is(chedc one). <br /> �GeRtticate of Gomplience—vaiid unhT(3 ree�s Nnnr defe of�epo�tJ: 5/Z111(Tt� -- <br /> ❑Alotice of NonCc+mp6ar�oe-�ar Noncompliartt sy8tems: <br /> The teasvn 4or noncd'r�ptience is: <br /> Th!s noncompliant syseem ia classlfled os�check ons bslow): <br /> ❑Imminent threat to pubiic health 8 sefet� ❑FaiCmg to p�oteCt ground weter ❑Not in oomplianc�wIM operating permit <br /> GertifiCation�comp�eed torr„m��$uamnc�to tr,e ro�r�r,�or9o�e�w��m Ts days.� <br /> r nereby ce,vfy fhar aN rhe neoessary rnJbrmeaon hes aeen gaUte�ed to deremdne me c�ompliance sretus af rn,s sysrem. nro <br /> tlet,enrdnetkxrofhrturesystempedarrrance hasbeen norcarr be made du9 to uM�'�Cwn condiQons during sysfem constnrction, <br /> Possi+�le AbtrS6 O(fhe syst�em,irtadequefe mainlertanCe,Ot'flilti/e tvBl+9r usege. <br /> Name: Jose�h J.Olso� CertNk.etlon number, t255 <br /> Business Ilcense�an�e and rxuttber: Rusty Olsods 9oI!end P�u1a�n lestin�i L�C�8a0 or <br /> Name ot local unit af govemment: C� of Orv�a <br /> SigneNra: ^�'� _ Date: 6/25l10 <br /> Required Attachments �nspedor Cors�pls�:�his Insp�tlon Report��pages long. <br /> CheCk comp1i81�C�fOrntB 4tffiChed: �li�draulic Perfom3anCe 0 T�nk Inte�riiy �Soil SepareNo� �Opersting Pertnit Fortn tl� <br /> appllcabb) ❑Systnm drswinglAs-built brsivvinQ ❑An a�eeaement of any to�t rsqul�rnants that aro dif(erent irom what is requirod on thla <br /> form �50l Horing Lops ❑Abendonme►�tort►+C+�ePProP►�a�1 C��f inf6mfaG6ff�tr <br /> Upqrade Requtrements(derived trom Afrm.StaG§t t5�55)n�r�,r�e�r rn�e.��o puouc neaRn sov arieo�f�r�rs�mosr ne upprecec.repacoa.or <br /> rts w.w000ntnu�ad Nawn ren mwdha or.eoaipt ol Haa noeroe a�dAln s snorlsr pnloa arevw�ed ar�bca��du,arxe.n ene syatem 1a 1pWnQ to a�orea o�ound <br /> wp�er,fhe ayatem muat be uppiaded,reptso9A.a Rs uas atr[ditlr►ued�In t�+o tbno�eQui+ed by bcst aeManoe.Nan ixlmfU+p eyetem ia nof fei�'np ea deRned in <br /> �:aae I►aa at l�ast I�.n Ibef ol0�afpn solssOnsRon,men p�e sY�+�naed rwf ee nppred��ep�roe,�sptet�t0,a Ite use dl�ntirn,e0,noA+�fal►►0�Y <br /> ACB!ol0lnalrce U�et!e mwe 8Md 77+1a plowaion daec iw?apply M syatsma M SAalNand NMs,YVeIA►9ad?ivleciion A�sas.or Naa�uaed!n connedion M7'dr bal, <br /> De►erape,and Indginp e�ments aa defned in bw. <br /> wq•wwists4-3t Ccmplionre IrtspectTon fom►for Ex►sting SSTS <br /> �/4/0B- <br />