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. Minnesota Pollution Compliance Inspection Form Control Agency 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems St.Pa�l,MN 55155-4194 �$$T$� Doc Type:Compliance and Enforcement Instructions: Inspection results based on Minnesota Pollution Control Agency(MPCA) For local tracking purposes: requirements and attached forms—additional local requirements may also apply. Submit completed form to Local Unit of Government(LUG)and system owner within 15 days System Status System status on date(mm/dd/yyyy): 4/23/2012 � Compliant- Certificate of Compliance � Noncompliant- Notice of Noncompliance (Valid for 3 years from report date, unless shorter time (See Upgrade Requirements on page 3) frame outlined in Local Ordinance.) Reason(s)for noncompliance (check all applicable) ❑ Impact on Public Health (Compliance Component #1)—Imminent threat to public health and safety ❑ Other Compliance Conditions(Compliance Component#3)—Imminent threat to public hea/th and safety ❑Tank Integrity(Compliance Component #2)—Failing to protect groundwater ❑ Other Compliance Conditions(Compliance Component#3)—Failing to protect groundwater � Soil Separation(Compliance Component #4)—Failing to protect groundwater ❑ Operating permiUmonitoring plan requirements(Compliance Component #5)—Noncompliant Property Information Parcel ID#or Sec/Twp/Range: 04-117-23-44-0002 Property address: 2555 Fox Street, Orono, MN 55391 Reason for inspection: Transfer of Title Property owner: Peter Eckerline _ Owner's phone: or Owner's representative: __ Representative phone: Local regulatory authority: City of Orono _ Regulatory authority phone: Brief system description: 2 1000 pre-cast se�tic tanks,(1)1000 gal pre-cast pump tank, 350 lin ft of rock trench drainfield. Comments or recommendations: System failed due to lack of a seperation from the bottom of the rock trenches to the seasonal water table. The tanks were pumped and are in compliance. Certification I hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No determination of future system performance has been nor can be made due to unknown conditions during system construction, possible abuse of the system, inadequate maintenance, or future water usage. Inspector name: Per " ' entges Certification number: ---- -----------------_-- Business name: Chi ' Se tic Se ' e' License number: _2064 -- . Inspector signature: �.� __ _ Phone number: 952-200-3176 Necessary or Localty Required Attachments � Soil boring logs �f System/As-built drawing ❑ Forms per local ordinance ❑ Other information(list): —_ _-------- --------------- — www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats wq-wwists4•31 • 1/24/12 Page 1 of 4