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' - <br /> Minnesota Pollution Compliance Inspection Form <br /> ��:; ��' Control Agency <br /> 520�afayette Road North Existing Subsurface Sewage Treatment Systems <br /> St.Paul,MN 55155-4144 (SSTS) <br /> Doc Type:Compliance and Enforoement <br /> Instructions: inspection results based on Minnesota Pollution Control Agency(MPCA) for local tradcing purposes: <br /> requirements and attached forms—addi6onal locai requirements may aiso apply. <br /> Submit complebed form to Local Unit of Govemment(LUG)and system owner f <br /> within 15 days � T � <br /> System Status <br /> System status on date(mmJdd/yyyy): 1/9/2014 <br /> ❑ Compliant-Certificate of Compliance � Noncompliant- Notice of Noncompliance <br /> (Valid for 3 years from r�port date, unless shorter time (See Upgrade Requiiements on page 3) <br /> frame outlined in Local Orolinance.) <br /> Reason(s�for noncompliance(check all applicable) <br /> ❑ Impact on Public Health(Compliance Component #1}—tmmirtenf threat to public health and safety <br /> ❑Other Compliance Conditions(Compliance Component�i3)—lmminenf threaf to public health and safety <br /> ❑Tank Integrity(Compliance Component #2)—Failing to protect gn�undwater <br /> ❑Other Compliance Conditions(CompNance Component#3)—Failing to protect groundwater <br /> �Sal Separation(Compliance Component #4)—Failtng#o protect grroundwater <br /> ❑Operating permitlmonitoring ptan requirements(Compliance Component #5)—Noncompliant <br /> Property Information Parcet ID#or SeclTwp/Range: 10-117-23-32-0014 <br /> Property address: 1270 French Creek Drive.,Orono, MN Reason for inspection: Property Transfer <br /> Property owner_ Andrea Mueller __ Owner's phone: 612-369-0414 <br /> or <br /> Owner's representative: ____ Representative phone: <br /> Local regulatory authority: City of Orono Regulatory authority phone: 952-249-4600 <br /> 2-1000 gallon septic tanks, 1-1000 Gallon lift station and approximately 750 square feet of trench per <br /> Brief system descnption: city records <br /> Comments or recommendations: <br /> �ertification <br /> t hereby certify ti►af aN the necessary information has been gathered to detennine the comp(iance sfatus of th+s system. No <br /> determination of futur�sysfem performance has been nor can be made due to unknown conditions during system const�uction, <br /> possible atruse of the system, fnadequete mairrtenance, or future water usage. <br /> Inspector name: Joseph J Olson Ce�tification number: 1255 <br /> Business name: Rusty Olson's Soil&Perc.Testing License number: 810 <br /> Inspector signature: _______ ___ Phone number. 763-498-8779 � <br /> Necessary or Locatty Required Attachments <br /> �Soil boring logs �System/As-built drawing ❑Forms per local ordinance <br /> ❑Other information(list): i � <br /> www.pca.state.mn.us • 65i-296-6300 • 800-657-3864 • TfY 651-282-5332 or 800-657•3864 • Available in altemative formats <br /> wq-wwists4-31 • tl24/12 Poge 1 of 3 <br />