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May 24 2015 04:15PM HP FaxRusty Olson 7634988290 page 2 <br /> Minnesota Pollution Compliance I nspection Form <br /> Control Agency <br /> Existing Subsurface Sewage Treatment Systems <br /> 520 Lafayeste Road North �SSTS� <br /> St.Paul,MN 55155-4194 <br /> Doc Type:Compliance anc'EMorcement <br /> Instructions: Inspection results based on Mlnnesota Pollution Controi Agency(MPCA) For local tracking��'vE� <br /> requirements and attached forms-additional local requirements may also apply. ` <br /> Submit completed form to Local Unit of Government(LUG}and system owner I MAY 2 6 2015 I <br /> within 15 days � -- — � <br /> C�'n(OF ORONO <br /> System Status <br /> System status on date(mrnlddlyyyy}: 5/15/2015 __ ___ <br /> � Compliant—Certiticate of Comptiance ❑ Noncompliant—Notice of Noncompliance <br /> (valid for 3 years from report date, unless shorfer fime (See Upgrade Requirements on page 3J <br /> irame oudined rn Loca!Ordrnance.} <br /> Reason(s}for noncompliance (check a/l appficable) <br /> ❑ Impact on Public Health (Compliance Component t�1)-fmm;nent th�at to public health and safety <br /> ❑ Other Cvmpliance Conditions(Compliance Component#3)-lmmrnent threat to public health and safety <br /> ❑Tank Integrity(Compliance Component #2}-Failing to protect groundwater <br /> ❑Oiher Campliance Conditions(Compfiance Component#3)-Failing to profect groundwater <br /> ❑Soil Separation(Compliance Component #4}-Failing to profecf groundwater <br /> ❑Operating permi�moniioring plan requirements(Compliance Component #5)-fVoncompJiant <br /> Property Information Parcel ID#or SeclTwp/Range: 101172332�013 _ <br /> Property address _1250 French Creek drive, Orono MN Reason tor inspection: Propert Transfer <br /> Property owner: Scott Danielson _ _ Owner's phone: _612-360-8313 _ <br /> or <br /> Owner's representative: RepreseMative phone: __ <br /> Local regulatory authority: City of Orono ___ __ Regulatory authority phone: 952-249�600 _ <br /> 2-1000 gallon septic tanks,l-1000 gallon IiN station and 550 square feet of mound rockbed.per city <br /> Brief system description: records ----- -- <br /> Comments or recommendations: <br /> Certification <br /> 1 hereby ce�fify that all the necessary information has been gathered to deterrr►ine the complia»ce status of this system. No <br /> determinatron of future system performance has been norcan be made due to unknown conditions during system construction, <br /> possible abuse of the system,inadequate mainfenance, or future water usage. <br /> Inspector name: Joseph J Olson _ CeRification number: 1255 _ <br /> Business name: Rust Is ' F&-Pera Testin __ License number: 810.. <br /> Inspector signature: ___ _ , __ _ _ Phone number: 763-498-8779 _ _ <br /> Necessary or l.ocally Required Attachments <br /> �Soil boring logs �i System/As-built drawing ❑ Forms per focal 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 altemative formats <br /> wq-wwists4-3f • 1/Z4/12 Pdge 1 of 3 <br />