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May 05 2015 03;14PM HP FaxRusty Olson 7634988290 page 2 <br /> , , <br /> � Minnesota Pollution Compliance Inspection Form <br /> Cantrol Agency <br /> 520LafayetteRoadNorth Existing Subsurface Sewage Treatment Systems <br /> St.Paul,MN 55155-419A � (SSTS) <br /> Doc Type�Compliarce and EnforCement <br /> Instructions: Inspection results based on Minnesota Pollution Control Agency(MPCA) I For local tracking purposes: � � <br /> requirernents and attached forms-additional local requirements may afso apply. � RECEIVED <br /> Submit completed form to Local Unit of Govemment(LUG)and system owner ' <br /> within 15 days � MAY ��-,�Q�� _ <br /> System 5tatus <br /> cmr oF oRONo <br /> System status on date(mmldd/yyyy): 5/112015 <br /> � Compliant-Certificate of Compliance ❑ Noncompliant- Notice of Noncompliance <br /> (Valid for 3 years from report date, unless shorter fime (See Upgrade Requir�ments on page 3) <br /> frame ou8rned in Loca!Ordinance.) <br /> Reason(s)for npncomplianCe (check all appli�able} <br /> ❑ Impact on Public Health(Compliance Componcnt #9)-lmminent threat to public hea(th and safety <br /> ❑Other Compliance Conditions(Comp/rance Component#3)-Imminent rhreaf to public health�nd safety <br /> ❑Tank Integriiy (Compliance Component #2)-Failing fo protect groundwater <br /> ❑Other Compliance Conditions(Compliance Component#3)-Failing to protect groundwafer <br /> ❑Soil Separation(Compliance Cnmponent #4)-Failing fo profect qroundwafer <br /> ❑Operating permiUmonitoring plan requirements (Compliance Component #Sj-Noncompfianf <br /> Property Information Percel ID#or Sec/Twp/Range: 0511723120026 <br /> Property address: 3420 High Lane, Orono, MN _ Reason for inspection: Pro�erty Transfer <br /> Property awner: Wesley WolveRon Owner's phone: 952-473-9126 <br /> or ---- --__ <br /> Owner's representative: ftepresentative phone: <br /> Local regulatory authority: Ci�of Orono _ Regulatory authority phone: 952-249-460� <br /> 2-1000 gallon septic tanks,l-1000 gallon lift sta�ion and 380 square feet of mound rockbed. per city <br /> Brief system descriptian: records <br /> -____ --- <br /> Comments or recommendations <br /> Certification <br /> !hereby cerfify that aI!lf�e necessary information has been gathered to determine the compfiance sfatus of this system. !Vo <br /> determination offuture system performance has been r�orean be made due to unknown eonditrons dunng system consfn,ction, <br /> possible abuse of fhe system, inadequate maintenance, or future water usage. <br /> Inspector name: Joseph J Olson Certificaticn nurnber: 1255 <br /> Business name: Rust OI n's Soil�Perc. Testin License number: 8�0 <br /> Inspector signature: _ Phone number: 763-498-8779 <br /> Necessary or Lacally Required Attachments <br /> � Soil boring logs � SystemlAs-built drawing ❑ Forms per local ordinance <br /> ❑ Other information(list): <br /> www.pca.state.mn_us • 651•�96-6300 • 800-657•3864 . TTY 651-282-5332 or 800•657-3864 • Available in attemative formats <br /> wq-wwiscs439 • 1/24l t2 Page 1 of 3 <br />