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y Minnesota Pollution ' <br /> 5��� ;n� ControlAgency Compliance Inspection Form� <br /> ,,.�..����� <br /> 520 Lafayette Road North ��Sting Subsurface Sewage Treatment Systems <br /> St.Pdui,MN 55155-4194 �ggTs� <br /> Doc 7ype:CompUance and Enfor�ement <br /> Insti'uctions: Inapec�tion results based on Minnesota Pollution Control Agency(MPCA) For iocai tracking purposes: <br /> requirements and attached forms—additional local requirements may also apply. <br /> 3ubmit completed form to Local Un(t of(3overnment{LUG)and system owner <br /> within 18 days <br /> System Status <br /> 3ystem status on date(mm/dd/yyyy): 217/2014 <br /> �Compliant—Certlficate of Compliance ❑ Noncompliant—Notice of Noncompliance <br /> (Valld for 3 years from report date,unless sho�ter Nme (See Upgrade Requfrements on page 3) <br /> frame outiined In Local Ordinance.J <br /> Reason(s)for noncompliance(check all epplJcab/e) <br /> ❑Impact on Pubfic Heaith(Compllance Component #1)—Imminent fhreat to publfc health and sefety <br /> ❑Other Compliance CondiUons(Complfance Componenf#3)—Imminent fh�af to publlc health and safety <br /> 0 Tank Integrity(Compliance Component #2)—Failing to profect groundwater <br /> ❑Other Compliance Conditfons(Compltance Component�.?)—Failing to protect groundweter <br /> ❑So(I Separa8on(Compliance Component #4)—Falling fo protect gruundwater <br /> ❑Operating permit/monitoring plan requirements(Compllance Component #5)—Noncompllant <br /> Property Information Parcel ID#or SecJTwp/Range: 35-118-23-340015 <br /> Property address: 1260 Lyman Ave.,Orono,MN Reason for inspection: Pr�perty Transfer <br /> Property owner: Michael Sweeney Ownet's phone: <br /> or <br /> Owner's representetive: Scott Acker Representative phone: 812-382-1314 <br /> Local regulatory autho�ity: City of Orono Regulatory authoriry phone: 962-249-4800 <br /> 2-1300 gallon septic tanks,l-1300 gallon lift statlon and 500 squere feet of mound rockbed.per city <br /> B�ief system deacription: records <br /> Comments or recommendatlons: <br /> Certification <br /> 1 hereby cerNfy tfiat al!fhe necessary infor►natlon has been gafhered to determine the compliance sfatus of fhls system.No <br /> determinatfon of futu�a system pe�rrnance has been nor can be made due fo unlv�own condiflons during system constniction, <br /> posslble abuse of fhe system,inadequate mainfenance,or futu►e wafer usage. <br /> inapector name: Joseph J Olson Certiftcation number: 1255 <br /> Business name: Rus Ison's Soll&Perc.Testin License number. 810 <br /> Inspector signature: Phone number. 763-498-8779 <br /> Necessary or�Locally Requ9red Attachments � <br /> �Soil boring logs �System/As-bui(t drawing ❑Forms per local o�dinance <br /> ❑Other informatlon(list): <br /> www.pca.state.mn.us • 651-296-6300 • 500-657-3864 . TTY 651-282•5332 or 800•657-3864 • Avatlab(e in altemative forrnats <br /> wq•+vwlsts4-3i • f/24/12 Page i of 3 � <br />