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�� <br /> ,, � <br /> � Minnesota Pollution Compliance Inspection Form <br /> ��s�`��� Control Ag�ncy <br /> s2o�a�ayeae Road�orcn Existing Subsurface Sewag� Treatment Systems <br /> SL Paui,MN SSt55-4194 ($$T$) <br /> Doc Type:Compliance and Enfaaement <br /> Instructions: Inspection results based on Mi�nesota Pollution Control Agency(MPCA) ' For local tracking purposes: � <br /> requi�ements and ettached fortt�s-additional local requirements may also apply. ' <br /> Submit completed form to�ocal Unit of Government(LUG)and system awner � <br /> within 15 days <br /> System Status <br /> System status on date(mm/dd/yyyyj: 6h6/2017 _ <br /> � Compliant— Certificate of Compliance ❑ Noncomptiant— Notice of Noncompliance <br /> (Valid for 3 years from report date, unless shorter 6me (See Upgrade Requirements on page 3) <br /> frame oudined in Local Ordinance.) <br /> Reason(s)for noncomptiance(check all applicable) <br /> ❑ Impact on Public Health (Compliance Component #1)-lmminenf threat to pubkc heattn and safety <br /> ❑Other Compliance Conditions(Compliance Component#3)-Imminent thr�at to public health and safety <br /> ❑Tank fntegrity(Gompliance Component #2)-Faiting to protect groundwater <br /> �Other Compliance Conditions(Comptiance Comp�►ent#3)-Failing to protect groundwater <br /> ❑ Sail Separation (Compliance Component #4)-Faiting to protect groundwafer <br /> ❑Operating permiUmonitoring plan requirements(Compliance Componenf #5)-Noncompliant <br /> Property Information Parcel ID#or SeclTwplRange: 0411723120017 <br /> ..._. <br /> Property address: 2755 Co�ntryside Drive W,�rono MN Reason for inspection: Property Transfer <br /> Property owner: Robert Tunhein _ _ � Owner's phone: 612-251-6106 y <br /> or ___ .._.... __......�. <br /> Owner's representative: �� _ Re resentative ho�e: <br /> P R _ __ __ ____.. <br /> Local regulatory authority: City of Orono _ Regulatory autharity phone: _952-249-4600 _ <br /> .. _. <br /> Approximately 2-1300 gallon septic tanks,l-13Q0 gallon lift station and 680 square feet of mound <br /> Brief system description: rockbed. <br /> _ —�___ _..._.. _....._ ____� <br /> Camments or recommendations: <br /> TBM:Top of lift station manhole cover <br /> Certification <br /> 1 hereby certify that alf the necessary rnformation has been gather+eci to detemrine fhe compliance status of this system. No <br /> determination of future system perfamaance has been nor can be mede due ta unkrrown condifions during system constrr�ction, <br /> possible abuse of the system, inadequate maintenance, or futur�s water usage. <br /> Inspector name: Joseph J Olson Certification number: 1255 <br /> _.. _.. _.__ __ ____ <br /> Business name: Rust OI s Soil&Perc.Testin License number: 810 <br /> ___...- --__ ._ <br /> Inspector signature: _ Phone number: 763-498-8779 <br /> Necessary or Loca((y Required Attachments <br /> � Soil boring logs � System/As-built drawing ❑ Forms per local ordinance <br /> ❑Other information(list}: <br /> � .. ___— _...._... __. __ _.... <br /> www.pca.state.mn.us • 651•296-63� • 800-657•3864 • TTY 651-282-5332 or 800-657-3864 • Avaitable in altemative formats <br /> Wo-wwists4-31 . 1/24112 „ . ., <br />