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Oct 10 14 12:07p Joseph Olson 763-498-8290 p.2 <br /> . � <br /> Minnesota Pol6ution Compliance Inspection Form <br /> Co�tral Agenty <br /> SZOlatayetieRoadFVorth Existing Subsurface Sewage Treatment Systems <br /> 5t.Pauf,MN 55155-4144 �$$TS� <br /> Doc Type:Compliance and En(orcement <br /> For loeal trackin —� <br /> Instructions: inspection results based on Minnesata Potlution Control Agency(MPCA) ���yED I <br /> requiremenis and attached forms—addfional local requirements may also apply. � I <br /> Submit completed form to Locar Unitof Govemment(LUG)and system owner i �1��^ � 3 � <br /> within 45 days u 1 ��14 <br /> System Status <br /> CITY OF ORONO <br /> System status on dat,e�rr�mfddlyyyy): 10/7/2014 <br /> � Compliant-Certificate of Compliance � Noncompliant- Notice of Noncompliance <br /> {Valid for 3 years from reporf date, unless shorter time {See Upgrade Requirements on page 3) <br /> frame outlined in Loca(Orziinance.J <br /> Reason(s)for noncompliance (check all appJicable) <br /> ❑ Impact on Public Health(Complrance Cornponent #1)—lmmrnent fhr�at to public health anc!safety <br /> ❑�ther Compliance Conditions(Complrance Component#3)—lmminent threat to public heafth and safefy <br /> ❑Tank Integrity(Compfiance Component #2)—Failing to protectgr�undwafer <br /> ❑Other Com�liance Conditions(Compliance Component#3)—Fai�ing to protect groundwater <br /> ❑Soil Separation(Compliance Componenf #4)—Faifrng to profect gr�undwater <br /> i� Operating permitlmonitonng plan requirements (Compliance Component #5)—Noncompliant <br /> Property Inforrnation Parcef IO#or 5eclTwp/Range: 04117-23-13-0006 <br /> Properry address: 2655 Cauntryside Dri�e W.,Orono, MN _ _ Reason for inspect9on: Property Transfer <br /> Property owner: _hJeil Levy _ � _ Owner's phone: 612-747-8265 <br /> or <br /> Owne�s representative: __ __ Representative phone: <br /> Local r�gulatory auihonty: City of Orono Regulatory authority phone: 952-249-4600 <br /> 2-1300 gallon septic tanks,l-1300 gallon lift statian and 630 square feet of mound rockbed.per city <br /> Brief system description: records <br /> Comments or recommendations: <br /> C�ftlflCd�'IOrI <br /> 1 hereby cerfify that a!1 the necessary informatian has been gaYhered to determine the compfrance status af this system. No <br /> determinaUon of future system performance has been nor can be made due to unknown conditions dunng system construction, <br /> possrble abuse of fhe system, inadequate maintenance, or future water usage. <br /> Inspector name: _Joseph J Olson _ _ _ _ Certifica#ion number: 1255 <br /> Business name: _Rusty _Ison's Soil 8�Pe stin� � License nurnbec 890 A <br /> Inspector signature- _____ Phone nurnber: 763-498-8779 <br /> Necessary or L�calty Required Attachments <br /> �Soil boring logs �System/As-buift drawing ❑ Forms per local ordinance <br /> ❑Other information(list}: <br /> wvrw.pca.state.mn,us • b51-296-636Q - 800-657-3864 • TfY 651•Z82-5332 or 800-657-3864 • Available in aitemative formats <br /> wq-wwrsts4-31 � 1/Z4112 <br /> Poge 1 of 3 <br />