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Sep 30 2016 06;06AM HP FaxRusty Olson 7634988290 page 2 <br />. ' <br /> Minnes�ta Pollution Compliancc inspection Form <br /> Control Agency <br /> 520l.afayetteRoadNorch Exlsting Subsurface Sewage Treatment Systems <br /> St.Pa�,MN 55155-4194 {$$77�5) <br /> Doc 7ype:Comp!lance and Er►faroement <br /> Instructions: Inspection results based on Minnesota Pdlution Control Agency(MPCA) For local tracking puryoses; <br /> requirements and aftached forms—additional lacai requirements may also apply. RECEIVED ' <br /> Submit complebed form to Local Unit of Oovernment(LUG)and system owner <br /> within 15 days <br /> System Status CITY OF ORONO <br /> 8ystem statius on date(mmlddtyyyy): 9/2l2016 <br /> �Compliant—Certi�cate of Compfiance ❑ Noncompliant—Notice of Noncompliance <br /> (VaJid for 3 years from roport date, unless shorter time (Sse llpgrede Requirements on page 3) <br /> frame oudined in Local Ordinance.) <br /> Reason(s)fcr noncomplianae(check al/appllcable) <br /> ❑Impact on Public Health (Compliance Component #i)—lmminent threat to public health and safety <br /> ❑Other Complianoe Condiiions(Compflance Component#3)—Irnminent thieat to public health and safety <br /> ❑Tank I rrtegrity(Compliance Component #2)—Fai�ing to protect groundwater <br /> ❑Other Compliance Conditions(Compliarnae Component#3)—�ailing to protec!groundwater <br /> ❑Soil Separation(Cornpllance Component #4)—FaNing fo protecf groundwefer <br /> ❑Operat+ng permiUmonitoring plan requirements(Compfiance Component #5)—Noncompliant <br /> Property Information Parcel ID#or Sec/TwplRange: 25-118-23-43-0012 <br /> Property address: _280 Holiander Road, Orano,MN Reasan for inspection: Property Transfer <br /> Properiy owner. Jill Payne Owner's phone: 612-889-2564 <br /> or <br /> Owner's representative: Representative phone: <br /> Locaf regulatory authority: City of Orono Regulatory authority phone: 552-249-46p0 <br /> Approximately 2-1300 gallon septic tanks,�-1300 gallon liR station and 63�square feet of mound <br /> Brief system description: rockbed. <br /> Comments or recommendations: <br /> Certification <br /> 1 hereby certl/y thaf a11 the necessary informatlon has been gathensd tn detertnine the compliance stetus of this sysfem.A!o <br /> determination of future system performance has been nor can be made due to unknown cond'dions during system conatruction, <br /> possible abuse of fhe system,inadequate maintenance,or future water usage. <br /> Inspector name: Joseph J Olson Certfication number: 1255 <br /> Business name: Rus 01 on's Sail&Perc.Testin License number: 810 <br /> Inspector signature: Phone number: 763-498�779 <br /> ✓ <br /> Necessary or Locally Required Attachments <br /> � Soil boring logs �SystemlAs-built drawing ❑ Forrns per local ordinance <br /> ❑OUter ir�formation(list}: <br /> www.pca.s[ate.mn.us • 651-29b6300 • 800-657-3864 • TTY d51-282-5332 or800•657-3864 • Available in alternative formats <br /> wq-wwtsts4-31 . 1124/12 p� r o f 3 <br />