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<br /> :5 t�"'�,�So�� �°����'°" RECErvEo Compliance Inspection Form
<br /> " s.�� �� Cor�trol Age�cy
<br /> � szo�a�ayerte�oaa tvorth AUG 21 20 F�'sting SubsurFace Sewage Treatment Systems
<br /> st.Pau�,MN 55155-4194 (SSTS)
<br /> CITY OF ORONO Doc Type:Compliance and Enfor�ement
<br /> Instructions: Inspection results based on Minnesota Pollution Control Agency(MPCA) For local tracking purposes:
<br /> requirements and attached forms-additional local requirements may also apply. RECE�VE�
<br /> Submit completed form to Local Unit of Government(LUG)and system owner
<br /> within 15 days �i ir_ � 1 �f11A
<br /> _ �----
<br /> System Status CITY OF OROND
<br /> System status on date(mm/dd/yyryy):
<br /> �ompliant— Certificate of Compliance ❑ Noncompliant— PVotice of Noncompliance
<br /> (Valid for 3 years from report date, unless shorter time (See Upgrade Requirements on page 3)
<br /> frame outlined in Local Ordinance.)
<br /> Reason(s)for noncompliance (check all applicable)
<br /> ❑Impact on Public Health (Compliance Component #1)-fmmrnent threat to public health and safety
<br /> ❑Other Compliance Conditions(Compliance Component#3)-lmminent threat to public health and safety
<br /> ❑Tank Integrity(Compliance Component #2)-Failing to protect groundwater
<br /> ❑ Other Compliance Conditions(Compliance Component#3)-Failing to protect groundwater
<br /> ❑Soil Separation(Compliance Component #4)-Failing to protect groundwater
<br /> i. .1 r)nar�tinn nr rrnit/mnnjtCCl^g�la,^,rsG�:reme^ts(Com,p!:a^c�Com,per,cnt #5) Nor,ccmpliant
<br /> �..�._... � �.,..,
<br /> Property Informafiion Parcel ID#or Sec/Twp/Range:
<br /> Property address: 7'�5/ ��„f�t•�, �,,��(� .J,t,__ Reason for inspection: ;�',��r
<br /> Property owner: _ _ _ _ Owner's phone:
<br /> or
<br /> Owner's representative: _ _ _ Representative phone:
<br /> Local regulatory authority: ��(,�___��� p,��,�,� _ Regulatory authority phone: _
<br /> Brief system description:
<br /> ---- — ---- --- —-------- —
<br /> Comments or recommendations:a„ %!?a�'f,E J S 4'/� ��r .�s�N,��y �_ �p�a• ���,�,�� �L,�f w k
<br /> P�O b4� /�'G �G1 I e CY �/�£ 3 ��/ r� J `r.S��.t.�� . / 0��� � �C C/� /J tc✓
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<br /> Certification /�„�•z..,,,�� � �� F3c a rL�c,( ��N � y 6�r�1',Qo�,,,_
<br /> ° Gj'1 c �m^.c�x',c`;,��f�_.:.
<br /> I hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No
<br /> determination of future system performance has been nor can be made due to unknown conditions dunng sysfem construction,
<br /> possible abuse of the system, inadequate maintenance, or future water usage.
<br /> Inspector name: ,�� �,�,s, �„u�,v __ Certification number: �,Jr�,
<br /> Business name: /!y� j�tiv `��j� ,1.`"�. �.,,_�� ���, ,�`, License number. �1
<br /> Inspectorsignature:���� l,�,t,�"- " _ __ Phonenumber. 7G3- y���. /J�O --
<br /> Necessary or Locally Required Attachments
<br /> ❑ Soil boring logs ❑ System/As-built drawing ❑ Forms per local ordinance
<br /> ❑ Other information (list):
<br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 � Available in alternative formats
<br /> wq-wwists4-31 • 1/24/12 Poge 1 of3
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