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Jul 12 13 06:38a Joseph Olson 763-498-8290 p.2 <br /> r �' <br /> Minnesota Pollutian � Compliance Inspect�on Form <br /> Control Agency � <br /> 520 La€ayette Road North ��sting Subsurface Sewage Treatrnent Systems <br /> St Pdul,tN�!55155-4144 ��!� (SSTS� <br /> Doc Type:Complianca and Enfoicement <br /> In$tnac#ions: Inspection results based on Minnesota Po€lution Contral Agency(MPCA) ' Far local tracking purposes� <br /> requirements and attached forms—additional loql requirements may also apply. <br /> Submit completed form to Local Unit of Government(LUG)and system owner � <br /> within 15 days <br /> $)/5tE11'1 $tdtUS <br /> System status on date(mm/ddlyyyy): 7J2/2013 <br /> � Compliant-Certificate of Compliance ❑ Noncompliant- Notice of Nancompliance <br /> (Vafid for 3 years from report date, unless shorter fime (See Upgrade Requrremenfs on page 3} <br /> frame outlined in Loca!Ordinance.) <br /> Reason(s)for noncompliance(check al!applicable) <br /> ❑ Impact on Public Heafth (Compliance Component #1)—Imminent threat to pu6lic health and safety <br /> ❑ Olher Complianoe Conditions(Compfiance Component#3J—lmminent threat to public health and safefy <br /> ❑Tank Integrity(Campliance Component #2)—Failing to prot�et groundwater <br /> ❑ Other Compliance Conditions(Compliance Componenf#3)—Farling to protect groundwater <br /> ❑ Soil Separalion (Compliance Component #4)—Failrng to protect groundwater <br /> ❑ Operat�ng permiVmonitoring plan requiremer�s{Compliance Component #5)—NoncompliaRt <br /> Property Information Parcel ID#or SeclTwplRange: 3211823240009 <br /> Property address: 3680 Jacobs Mill Road,Orono, MN Reason tor inspection: Property Transfer <br /> Property owner: D Steven Collins � Owner's phone: 952-4D4-1144 <br /> or <br /> Owner's representative: Gregg Larsen Representati�e phone; 952-473-3000 <br /> Local regulatory authority: City o#Orono Regulatory authority phone: 9v2-249�fiD0 <br /> 1-1260 and 1-100�gallon septic tanks,l-1250 gallon lift station and 630 square Feet of mound rockbed. <br /> B�ief system descr�ptio�: �er city records ' � <br /> -- -- <br /> Comrr3ents or recommendations: <br /> Certification <br /> !hereby ceitify that all the necessary information has been gathcred to deterrnine the compliance sfatus of this system. No <br /> determination of fufure system perfarmance has been nor can be made due to unknown conditions dunng sysfem constrvcfion, <br /> possible abuse of fhe system,inadequate maintenance, o�future water usage. <br /> Inspectar name: Joseph J Olson Certification number: 1255 <br /> 8usiness name: Rusry�Ison's Soil& Perc.Testing License number: 81U <br /> tnspecior signature: � Phone nu�nber: 763-498-8779 <br /> Necessary or Local�y Required AttachmenEs <br /> �SoiJ boring logs � Systern/As-b�ilt drawing ❑ Forms per locat ordinance <br /> ❑O#her information(lisi): <br /> www.pcastate.mn.us • 651-296-63Q0 • 804-657-3864 • TTY651-282-5332 or 800-657-3864 • Available in alternative formats <br /> wq-wwis[s4-3! • f/Z4/12 Poge 1 of 3 <br />