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Jun 07 2016 07:49AM HP FaxRusty Olson 7634988290 page 11 <br /> � <br /> MinneSota Poilutian Compliance Inspection Form <br /> Control Agency <br /> SZOLafayetteRoadNorth ��sting Subsurface Sewage Treatment Systems <br /> St.Paul,MN 55155-4194 (SSTS� <br /> Doc Type�Complrance and Enfom.emeni <br /> RECEIVED <br /> Instructions; Inspection results based an Minnesota Pollution Control Agency(MPCA) I Fo cr o al tracking purposes� <br /> requiremenis and attached forms—additional local requirements may also apply. �IUN Q 7 2016 <br /> i <br /> Submit completed fortn to Local Unit of Government(LUG)and system owner <br /> within 15 days ' CITY OF O <br /> Systern Status ' <br /> System status on date(mmldd/yyyy): 5H7l2016 <br /> � Compliant- Certificate of Compliance ❑ Noncompliant-Notice of Noncompliance <br /> (Valid for 3 years frorn report date, unless shorfer time (See Upgrade Requirements on page 3) <br /> irame outllned(n Loca!O�dinance.J <br /> Reason(s) fo�noncompliance(check all applicable) <br /> [ Impact an Puolic Health (Compliance Component #!)—Jmmineni threat to public heaJth and safety <br /> C Other Compiiance Cond'+tions (Compliance Component#3}—lmminent threat to public healfh and safefy <br /> ❑Tank Integrity(Compliance Componenf #2)—Failing fo profectgroundwater <br /> ❑ Other Compliance Conditions (Compliance Component#3}—Fa;ling to protect groundwater <br /> C Soil Separation (Compliance Component #4}—Failing to protect groundwater <br /> ❑ Operating permiUmonitoring plan requirements(Compliance Component #5J—Noncompliant <br /> Property Information Parcel ID#or Sec/Twp/Range: 04-117-23-34-0002 <br /> Property address: 2879 Farview Lane., Orono,MN Reason for inspection: Property Transfer <br /> Property owner: James&Amy L�oyd Owner's phone: 612-310-7683 <br /> or - <br /> Owner's representative: f2epresentative phone: <br /> Local regulatory authority: City of Orono` Regulatory authority phone: 952-249-4600 <br /> 2-1000 gallon septic tanks,l-1000 gallon lift station and 500 square feet of mound rockbed.per city <br /> Brief system description: recards <br /> Comments or recommendations: <br /> Certification <br /> !hereby certify that al!fhe necessary infonnafion has been gathered to determine the compliance status of this sysfem. No <br /> determination of future sysfem performance has been nor can be made due to unknown conditions dunng system construction, <br /> possible abuse ofthe system, rnadequate maintenance, or future waterusage. <br /> Inspecior name: Joseph J Olsor, _ Certification number: 1255 <br /> Business name: Rust r Ison's Soil&Perc.Testing License number: 81Q <br /> Inspectorsignatur � ~"` _ Phone number. 763-498-8779 <br /> Necessary or LocalEy Required Atta�hments <br /> � Soil boring logs �Sysiem/As-built drawing ❑ Forms per iocal 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•3f • 1/24/i2 P�ge i ot3 <br />