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{ _�:. Minnesota Pollution Compliance Inspection Form <br /> . �-����-}�'�� Control Agency <br /> v..��:.. <br /> 520 Lafayette Road North �Sting Subsurface Sewage Treatment Systems (SSTSj <br /> SG Paul,MN 551 SS-4194 Doc Type:Complianoe and ErNaoement <br /> Inspection results based on Min�ta PoNution Control Agency(MPCA) For local tra�c�p��:� <br /> requirements and attadied forms—additi�onal local r�equirernents may also appty. <br /> ,..;�.. <br /> Submit completed fortn to Local Unit of Govemment(LUG)and syatem owner <br /> ;.fi:.-i� c t ��..l�L) <br /> witfiin 15 days C�'{�QFtONO <br /> System Status <br /> System status on date(mm/dcUyyyy): 12/16/2015 <br /> ❑ Compliant-Certificate of Compliance � Noncompliant- Notice of Noncompliance <br /> (Valid for 3 years from�port date, unless sharter time (See Upgrade Requiremenfs on page 3.) <br /> frame outlined in Local Ordinance.) <br /> Reason�s)for noncompliance(check all appllcable) <br /> ❑ Impact on Public Health(Con�liance Compone�r►t#1)—Imminent th►eat to pu�c health and safety <br /> ❑Other Compliance Conditbns(Compllance Component#3)—Imminent threat to public health and safety <br /> �Tank Integrity(Compliance Component#2)—Failing to protect groundwater <br /> ❑Other Compliance Conditions(Compliancs Component�13)—Failing to protect groundwater <br /> �soi�separation(corr�l�anoe componenr#a)—Faainy ro p►otect g�ow►dwarer <br /> ❑Operating pemiit/monitoring plan requirements(Compliance Componerrt#5)—Nonoompliar►t <br /> Property Information Parcel ID#or SeclTwp/Range: 31-11&23-42-0012 <br /> property address: 4220 Chippe�wa La Orono,MN 55359 Reason for inspection: Property Transfer <br /> Property owner: Owners phone: <br /> or <br /> Owner's representative: Independent Living Sduti�ons Representative phone: 612-743-7373 <br /> Local regulatory authoridy: City of Orono Re9��Y a�Y Pf�: 952-248�4600 <br /> Brief system description: 2 1000 gallon c�sspools <br /> Comme�s or recommendations: <br /> Unable to locate outlet pipe of 2nd tank, or any drainfield trencties or drair�'ield rock near or in vicinity of back yard. <br /> Certification <br /> 1 he�by cerfify that all the necessary information has been gathe�ed to determine the caompliarwe status of this system.No <br /> dete�mination of future system perfo►mance has been nor can be made due to unknown oonditions during sysfem c,onsfn�ction. <br /> pos,sible abuse of the system,inadequate maintenanoe, or futune water usage- <br /> Inspector name: Tristan Ende Certification number. C9206 <br /> Business name: E ' Service License number. L2654 <br /> Inspector signature: .T - Phone number. 763-428-4489 <br /> Necessary or Locally Required Attachments <br /> � Soil boring logs �SysteMAs-built drawing ❑ Forms per local ordinance <br /> ❑Other information Qist): <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TfY 651-2ffi-5332 or�657-3864 • Available in alt,c�►wtive formats <br /> n.,,� a nf t <br />