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� Minnesota Poflution Compliance Inspection Form <br /> Control Agency <br /> 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems <br /> St.Paul,MN 55t 55-4194 �$$T$� <br /> Doc Type:Compliance and Enforcement <br /> Instructions: Inspection results based on Minnesota Pollution Control Agency{MPCA) For local tracking purposes: <br /> requirements and attached forms-additional local requirements may 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(mm/dd/yyyy): 912/2016 <br /> � Compliant- Certificate of Compliance ❑ Noncompliant- Notice of Noncompliance <br /> (Valid for 3 years from report date. unless shorter hme (See Upgrade Requirements on paye 3) <br /> frame outlined in Local Ordinance.) <br /> Reason(s)for noncompliance (check al/applicable) <br /> ❑ Impact on Public Health (Compliance Component #f)-Imminent threat to public health and safety <br /> ❑ Other Compliance Conditions(Compliance Component#3)-Imminenf threat to public health and safety <br /> ❑Tank Integrity(Compliance Component #2)-Failing to protect groundwater <br /> ❑ Other Compliance Conditions(Compliance Component#3)-Failing to protect groundwater <br /> ❑ Soil Separation(Compliance Component �4)-Failing to protect groundwater <br /> ❑ Operating permiUmonitoring plan requirements (Compliance Component #5)-Noncompliant <br /> Property Information Parcel ID#or 5ecJTwp/Range 3311823430017 <br /> Property address: 2700 Copperview Drive. Orono, MN Reason for inspection: Property Transfer <br /> Property owner: Jeffrey& Elizabeth Peterson Owner's phone 612-747-1729 <br /> or <br /> Owner's representative: Representative phone: <br /> Local regulatory authority: City of Orono Regulatory authority phone 952-249-4600 <br /> Brief system description: 2-1300 and 1-1300�allon lift station and 680 square feet of mound rockbed. per city records <br /> Comments or recommendations: <br /> Certification <br /> I hereby certify that af(the necessary information has been gathered to determine the compliance status of fhis system. No <br /> determination of future system performance has been nor can be made due to unknown conditions during system construction. <br /> possible abuse of fhe system, inadequate maintenance. or future water usage. <br /> Inspector name: Joseph J Olson Certification number: i255 <br /> Business name: Rusty Olson's Soil& Perc. Testing License number: 810 <br /> Inspector signature: ---'��� Phone number: 763-498-8779 <br /> � <br /> �.--. <br /> Necessary or Locally Required Attachments <br /> � Soil boring logs � SystemlAs-buift drawing ❑ Forms per local 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•wwists4-31 • t/24/11 Poge 1 of 3 <br />