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Oct 15 09 p8: 19a Andy a Julie Kleindl (952] -442-9281 p. 2 � �I . . . Minnesota Poflution Compl�ance Inspect�on Form Control Agency 20 Lafayette Road North ��sting Subsurface Sewage Treatment Systems (SSTS) t Paul,MN 55155-4194 Instructions on page 7 Parcel number. 4� � For Local Tracking Purposes: System sta�us: Compliant ❑ Noncompliarrt .�� (based on�1!compliance r�quirements) ,, ' r , Summa�y Form ` � �� Propert � Information Property wner name(s): Property ddress: 763 Ferndale Road North, Orono MN �roperty wner's address(if d'rfferent): County: Henne in Property owner phone: 612-781-2321 Perrnitting authority: Carver Counry Pate sys m constructed: /��7 Reason for inspection: Property Transfer System escription �rief syst m description: a � C �k�,�Jkrrp�� r ✓�OG��HC�7PS �ocal pe it number: Numbe�of bedrooms: � Design flow rate: 1s the sy tem: In Shor fand area? �Yes ❑ No In Wellhead Protection Area? ❑Yes �] No j An U.5 Environmental Protection System serving a Minnesota Department 'I Agen (EPA)Class V Injection Well?❑Yes � No of Heath(MDH) licensed facility? ❑Yes �No CQftlp�Td Ce StdtUS(Based on state requirements-additional local requirements may also apply.) �ased on the information gathered and reported on attached forms,the oompliance status of this system is(check one): �Certifl te of Compliance-valid until (3 years from date of report): Notice of Noncompliance-For Noncompliant systems: The reason for noncompliance is: _ Thi noncompliant sysbem is classified as(check one below): ❑ I minent threat to public heatth 8�safety ❑ Failing to protect ground water ❑ Not in compliance with operating perrnit C�(t't1fIC 1011 (Completed form must oe submitted to the local unit of govemment within 15 days.) ll hereby rtify thaf a!/the necessary rnforma6on has been gafhe�d to defermine ihe compfiance sfatus of this system. No c�etermin "on of futu►e system performance has been nor can be made due to unknown conditions during system construction, Rossible buse of fhe system, inadequate maintenance, or future water usage. �lame: Andrew Kleindl Certfication number. 2926 �usiness icense name and number: Jim's Excavating &Pumping, LLC or �lame of I cal unit of govemment: Carver Coun �ignature _ � r Date: r��)�-!J°� ,r R�quire At�achments Inspector Complete: This Inspection Report is � pages long. �heck Co plianCe forms attached: f1�Hydraulic Performance ,�Tank Integrity �5oil Separation ❑Operating Permit Form(if iapplicab ) ❑ System drawing/As-built drawing ❑An assessment of any local requirements that are different trom what is required on this fortn j�Soil�oring Logs ❑Abandonment form('rf approp�ate} ❑ Other infoRnation(list): � I �� Up9r"d B R@qLLi�eR1EI7t5 (derived fiDm Minn. Stat.§195.55)An imminenf th�aat to public health and salety(lTPHSJ must be upgraded,replaced,or rts use d continued within ten months ofreceipt of this no6ce o�wdhin a shorter penod ifrequired byloca!ordlnance.If the system is failfng to proted ground ! water,th system must be upg2ded,replaced,orits use discontinued w!lhin Ihe time required by loca!ordinance.If an existing system is not farling as defined rn law,and as at least fwo feet of design soi!separation,thert the System need not be uppraded,repairecl,replaced,or its use disconf/nued,noAvithstanding any ' loca!ord ance that is more sinct. 7his provision dces not appty Jo systems in shoreland areas,Wellhead Protecthon Aieas,or thase useo'in connecUon wrth food, beverag,and/odging esfablishments as delned in law.