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' �: Minnesota Pollution Compliance Inspection Form <br /> �-u Controi Agency <br /> �' ' Existing Subsurtace Sewage Treatment Systems (SSTS) <br /> S20 Lafayette Road North <br /> ! St.Paul,MN 55155-4194 Doc Type:Compliance and Enforcement <br /> Inspe�tion results based on Minnesota Pollution Control Agency(MPCA) For local tracking purposes: <br /> require�nents and attached forms—additional local requirements may aiso apply. <br /> Submi�completed form to Local Unit of Government(LUG)and system owner <br /> within',15 days <br /> Systeim Status <br /> S�ystem status on date(mmJdd/yyyy): 5/9/2017 <br /> ❑ C�ompliant— Certificate of Compliance � Noncompliant— Notice of Noncompliance <br /> (Valid for 3 years from report date, unless shorter time (See Upgrade Requirements on page 3.) <br /> fi�ame outlined in Local Ordinance.) <br /> I�eason(s)for noncompliance (check all applicab/e) <br /> I ❑ Impact on Public Health (Compliance Component#1)—Imminent threat to public health and safety <br /> ', ❑Other Compliance Conditions(Compliance Component#3)—lmminent threat to public health and safety <br /> , �Tank Integriry(Compliance Component#2)—Failing to protect groundwater <br /> ', ❑ Other Compliance Conditions(Compliance Component#3)—Feiling to protect groundwater <br /> ' � Soil Separation(Compliance Componenf#4)—Failing to protect groundwater <br /> ', ❑ Operating permit/monitoring plan requirements(Compfiance Component#5)—Noncompliant <br /> Property Information Parcel IQ#or Sec/Twp/Range: <br /> Property address: 525 Ferndale Road N, Orono Reason for inspection: Sale <br /> Proper�y owner: James Ogland _ � Owner's phone: 612-986-4541 <br /> or ' - - <br /> Owner's representative: Representative phone: <br /> Local regulatory authority: Ciry of Orono Regulatory authority phone: <br /> Brief system description: 2 -block tanks and a gravitY rock trench <br /> Comments or recommendations: _-m�_. <br /> System had been inspected by city and labeled as non-compliant on 7/26/2001 and was supossed to be replaced by 12/31/2010 <br /> Certi�ication <br /> 1 hereby cerfify that all the necessary information has been gathered to determine the compliance sfatus of this system. No <br /> detem�rination of future system performance has been nor can be made due to unknown conditions during system construction, <br /> possible a6use of the system, inadequafe maintenance, or future water usage. <br /> Inspector name: Josh Swedlund � Certification number: C1659 <br /> Busine'ss name: Sewer Se ' s In License number: 2502 <br /> P � 9 Phone number: 952-873-3292 <br /> Ins ec or si nature: <br /> Nece�sary or Locally Required Attachments <br /> � Soil boring logs � System/As-built drawing � Forms per local ordinance <br /> ❑ O�ther information(list): � _ <br /> www.pcastate.mn.us • 651-296-6300 •�800-657-3864 • Ti'Y 651-282-5332 or 800-657-3864 • Available in altemative formats <br /> wq-wwi$ts4-31 • 3/16/12 Page 1 of 3 <br />