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04/22/2016 11 :47AM FA)t 9528733112 f�0001/0004 <br /> . , <br /> �� Minnesota Pollutian ��m1�-t tiance Ins ection Form <br /> Control Agenty 1�' p <br /> 520 Lafayette Raad North Exlsting Subsurf�ce Sewage Treatn�er�t Sy�#ems (SSTS) <br /> SL P2ul,MN 55155-4744 Doc Type:Campliance and Enfor��ment <br /> Inspectl011 resuks based on Minnesota Pollution Control Agency(MpCA) For local tracking purposes: <br /> requirements and a4tached forms—additlonai local requiraments may also apply. <br /> Suhrnit completed form to l.ar,al llnit of Government(LUG)and sysiem owner NrIC L L LU 10 <br /> withln 15 days <br /> CITV 0�ORON� <br /> System Status <br /> System status on date(mmlddlyyyy): 4/21/201fi <br /> � Compliant—Cel"tificate of ComplianGe ❑ Noncompliant—Noticg of Noncampli�n�e <br /> (Valid for 3 years from report dete, unless shorter time (5ee Upgr2ds Requirements on page 3.) <br /> frame outlined in Loca!Oid]nance.J <br /> Reason(s)fior noncompllance(check all applica6l�) <br /> ❑ Impact on Public Health(Comp/lance Gompenent#1J-Imminent threat fo public health and safery <br /> []Othei'ComplianCe Conditlo�s(Compliance Component�t,?)-/mminent threat to public haalth and saf�ty <br /> ❑7ank Integrity(Compliance Compa�ent#2)-Failing to protect groundwater <br /> �Other Compliance Conditlons(Compliance Component#3)-Failing b protect groundwater <br /> ❑ SOiI S9pardElon(Compliance Cofl7ponenf#4)—Falqflg to prpfeCt groundWatEr <br /> ❑Operating permit/monitoring plan requirements(CompNance Component#5J—lVoncomplrent <br /> Property Informatien Parcel ID#orSec/Twp/Ranqe: <br /> Property address: 1820 Fox Street Orono,Mn 55391 Reason for inspection: N/A <br /> Property owner. Lynne McDonou9h Dwner's phone: 612-839-4100 <br /> or — <br /> Owner's rep�esentative; Representative phqr�e: <br /> Local regulatory authority: _ Regulatory authority phone: <br /> Briaf system desc�ipdon: — <br /> Comments or recommendatians: — <br /> Certifi�ation <br /> I hereby eertify that a/!the necessery infnrmation l�as been gathered to determine the compliance status of this system_No <br /> determination of future System performance has bean nor can be made due to unknown conditlon8 during system constrUction, <br /> possib/e abuse of the system,inadequafv malntenance, or future water usage. <br /> Inspector name: Josh Swedlund Certificatlon number: C1659 <br /> Business name: Swedlund Se_tlC ServiCe L.iCense number: 2502 <br /> Inspe�torsignature: _ Phanenumb�r; 952-87}3292 <br /> Necessary or Locally Required Attachments <br /> �Sofl bonng logs � System/As-built drawing � Forms per lor,al ordinance <br /> ❑Other informetion(list): <br /> www-pca.state.mn.us • 657-z9b-6300 • 8Q0-b57-3864 • 7TY 651-282•5332 or800-657-3864 • AvailabEe in alternative formats <br /> wq•wwists4-31 . 3!7b/12 <br /> Pagefof3 <br />