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��,� `, ��es��a ��E��F�� omp�ianee Inspection �orrrl _ ��..Y- Contro(Agency Existi�sg Subsurfac� Sewage Treai�ent Systems (SS�`S) 520 Lafayette Raad f�or�CA SL i'aul,rrtl�f 5515.'a-4194 Doc Type:Compliance and Enforcement fnstructions on page 6 �ii11ti198t'�/ �O�'R'f (Campleted forsn must be submrtted ta the local unit of government within 15 days.) Parcel number. 27-1'18-23-31-OQ21 �For Local Tracking Purposes: System status: � Compi:ant ❑ Noncompliant � I (based on af!complianc�requiremenfsf � ', i , i Property �nfarmation oreperty ewner name(s): Property owner phone: ?roperty address: 1�20 Cox Farm Ro2d, Orono MN 55356 __.__ PropeRy owner address(f drf�erent): County: Henne i�n � Permitting authority: City of Orono Qate system constructed: Reason for inspection: Transfer of tifle System f�escriptio� Brief system description: Pre-cast Septic Tanics pump tank and above qrade drainfieid Local perrn�t number. Number of bedrooms: 5 Design flow rafe:� 750 fs the system: In Shorefand area? ❑ Yes � No fn WeI(head Protection Area? ❑Yes � No An U.S. Environmentaf Prote�ion System serving a Minnesota Department Agency(EPA}Gass V Injection We{I?�Yes � No of Heath(MDH) licensed facility? ❑ Yes � No C�i'il��1di�CE' $'��t15(Based on srate r�quiraments—additiona!local r�quirernents may also apply.} Based on ihe information gat}iered and reported on attached forms,the compliance sfatus of this system is(check one): � CertifiCate of Compliance—valid urtfil(3 years from dafe of repari): 7(21/2Q14 ❑ Notice of Noncompliance-For Noncompli2nt systems: The re�sen`or noncompliance is: This noncompliant system is classified as(check one below}: (� Imminent threat to public heaith 8�safety ❑ Failing to protect ground water ❑ Not in compliance wRh operatirrg permit Ceetification i he.�by certi`y that a/!the r�e�essary inforrnafion has been gather�c'fo defermine fhe compliance status af this system_ No determination or"future system performance has been nor can be made due io unknown cond�tions duRng syslerra construction, possible aduse ofthe system,inadequate marntenance, orfuture waferusage. Name: Pemef Hentr�es Certification numbec 2Q64 Business ficense na number. Chip's Septic Service LLC a� Name ef locai un� f govemme�- - _ Signature: �`" � Date: 7-21-11 , _ - -- �2eq�ired Attachments (`� Nydraulic PerFormance � Tank integriry ❑ 4perating Permit Form (if appiicable) � Sail Bori�g Lags � Soil Separatian � System drawing/As-buiit drawing ❑Arty local requiremenfs that are dif�erenf from whaf is required on this form ❑ Other infarma.icn(l�st): Upgrade Reqtsirements{de�ived fi'om Minn. St2t § 195.55)An imminenf threat to pubiic heafth and safefy(1TPHS}must be upgraded, replaced,or its use discantinued wirhin ten monfhs of receipf of this noSce or within a shorter period if required by loca!ordinance. !f the system is ' railing to pro�ect grourd water,ttre sy�em must be upgraded,replaced,or ifs use discontinued v�rithin the fime required by loca!ordinance. if an exisfing sysfem is not�i7ing as defrned in law, and has at feast hvo f�ef oi design soil separation, the�the system need not 6e upgraded,reparred, replaced,ar rts use discontinued,nohn�rthstandrng any local ordinance thaf is rnare strict This promsion does not apply to systems in shoreland areas, WeUhead Pro�ecfion Areas,or fhose used in connecnon with foad,beverage,and lodging establishments as defrned in(a�ac �v,�w.pca.state.mn.u� • 65T•246-6300 • 800-657-3864 • TiY 651-282-5332 or 800-657-3864 • Available in alterr�ative formats wq-wwists4-31 • 4/24/49