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May 27 14 12:12p Joseph Olson 763-498-8290 p.2 <br /> , <br /> �1{innesota Pollution Comptiance Inspection Form <br /> Control Agenty <br /> 520 Lafayetie f�oad North Existing Subsurface Sewage Treatment Systems <br /> SL Paui,MN 55155-4194 �$$'�'$� <br /> Doc Type:Complrance and Enforcement <br /> Instructions: Inspection resutts based on Minnesota Pollution Control Agency(Mi'CA) I For locai lracking purposes: � <br /> requirements and attached forms-additional local requirements rnay also appty. <br /> Submit completed form to Local Unit of Government(LUG)and system owner <br /> within 15 days <br /> System Status <br /> System status on date(mmlddlyyyy): 4/1212014 <br /> Q Compliant- Certificate of Compliance ❑ Noncompliant-Notice of Noncompliance <br /> (Vafid for 3 years from reporf date, unJess sho�ter fime (5ee Upgrade Requirements on page 3} <br /> frame ouflined in Loeal Ordinance.) <br /> Reason{s)for noncompliance (check all applicable) <br /> ❑ Impaet on Public Health (Compliarrce Component #1)-lmminentthreatfo pub/ic health and safety <br /> ❑Other Compliance Conditions(Compliance Canponent ft3)-lmminent threat to public health and safety <br /> ❑Tank Integrity(Compfianae Componenf #2)-Fa�ling to profect groundwater <br /> ❑Other Compliance Conditions (Compfiance Componenf#3)-Failing to protect groundwater <br /> ❑ Soil Separation{Cornpliance Component #4)-Failrng to prr�tect ground�vater <br /> ❑ Operating permiUmonitoring pfan requirements (Complrance Componenf #5)-Noncompliant <br /> Property lnformation Parcel fD#or Sec/Twp/Range: 04-11�-23-42-OOQ1 <br /> Property address_ 2660 Fox Street, Orono, IJ{N Reason for inspection: Pro e Transier <br /> --_ - --- �rn'---- ---- <br /> Property owner: Vernon Dane __ Owner's phone: <br /> or �� � <br /> Owners representative: Gregg Larsen _ Representalive phone_ 612-719-4477 <br /> Local regulatory authority: �of Orono _ __ Regulatory authority phone: 952-249-4600 <br /> Brief system description: 2-1000 and 1-1000 gaflon li�t station and 270 sguare feet of mound rockbed.per ciry records <br /> Comments or recommendations: <br /> Certification <br /> !hereby cerbfy thaf a1J the necessary informafron has been gathered to determine fhe compriance status of this system_IVo <br /> determination of(uture system performance has been rror can be made due fo unknown conditions during system constructron, <br /> possible abuse ofthe system, inadequate marntenance, orfuhrre wafe�usage. <br /> Inspector name: Jose�h J Olson Certification number: 1255 <br /> _ _ - - ---- <br /> Business name: Rusty Olson's Soif 8 Perc.Tesh� License number. 810 <br /> Inspecfor signature: Phone number: 763-498-8779 <br /> � - — - -- - <br /> Necessary or Locally Required Attachments <br /> � Soil boring logs �SystemlAs-built drawing C Fo�ms per local ordinance <br /> ❑Oiher information (list]: <br /> - — - - - ---- <br /> www.pca.state.mn.us • b51-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800•657-3864 • Available in alternacive formats <br /> wq-wwists4-3l • �11-t/12 Poge !of 3 <br />