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, ��finnesota Pollut'ron �Qmpliance Ins ection Form <br /> . Controi Agency P <br /> � 520 Lafayette Road North Exlsting Subsueface Sewage Treatme�t Systems <br /> SG Patd,MM 55155-4194 ($$TS� <br /> Doc Ty�:Compliance and Enforcement <br /> _. __ _. <br /> Instructians: I�spection results based on Minnesota Poilution Contral Agency(MPCA) For local tracking pu�oEs'vED , <br /> requirements and attached forms-additionai loeai requirements may a6so apply. � <br /> Submit completed form to Local Unit of Govemment(LUG)and system owner � <br /> within 15 days �"�A� o � ?��s <br /> System Status ���� <br /> System status on date{mmlddlyyyy): 512/2018 <br /> � Compliant—Certificate of Compliance ❑ Noncompliant—Natice of Noncompliance <br /> (Valid for 3 years from reporf dete, unless sharter dme (See Upgrade F?equirements on page 3) <br /> frame outlinad in Local Qrdinance.) <br /> Reason(s)for noncompliance(check all applTcable) <br /> ❑ Impact on Public Health (Compliance Companenf #1)-lmminent fhreat[o pubtic health and safety <br /> ❑Other Compliance Conditions(Corrrplianee Com�ent#3)-lmminent threat to pub!!c health and safety <br /> ❑Tank Integrity(Compliance Camponenf #2)-Failing fo protect groundwater <br /> ❑Other Compliance Conditions(Compliance Component#3)-Failing to protect groundwafer <br /> ❑ Soil Sepa�ation(Compliance Component #4)-Failing to protect groundwater <br /> ❑ Operating permiUmonitoring plan requirements(Carnpliance Component #5)-Noncompliant <br /> 130 JVI,a.v►o-�' �c.�'�� <br /> Property Informa �on Parcel iD#or Sec/Twp/Range: 04-117-23-11-0025 <br /> _._�e � __ <br /> Property address: 1 Manor Circle�_Orono, MN Reason for inspection: Pro e Transfer <br /> --._.__ �. __ __-_ <br /> Property owner: Julie Morrison Owner's phone: 812-708-2556 <br /> .._ .._._ ____..�.. __ _. <br /> or <br /> Owner's representative: _ _ Representative phone: <br /> �..._._ _----- <br /> Loca!regula#ory authority: Ci of Orono ___ Regulatory authority phone: 952-249-4600 <br /> - ---_- -�- <br /> Approximately 2-1000 gaAon septic tanks,l-10U0 gatlon lift station and 630 square feet of mound <br /> Brief system description: rockbsd. <br /> _ _ _ _ _---.. — ____...__---.__ . _ .. ____ <br /> Comments or recammendations: <br /> Certification <br /> I hereby certify that al1 the necessary information has 6een gathered to determine fhe compliance status of this system. No <br /> detemrination of future system pe►formance has been nor can be rrrade due ta unknawn conditions during system construction, <br /> possible abuse of the system,inadequate maintenarrce, or future water usage. <br /> Inspecto�name: Joseph J Olson __ __ _...........� eertification number. 1255 <br /> --_.���__---...._ _ __ <br /> Business name: Rust�+ on's Soil&Perc.Testing__ License numbsr: 810 <br /> _ _��w __ <br /> Inspector signatur • _ _ �'�"�� _ Phone number: 763-498-8779 <br /> Necessary or Localty Required Attathments <br /> � Soil boring logs ❑System/As-built drawing ❑ Forms per local ordinance <br /> ❑ Other information (list): <br /> _._._ ____.__ __ _ ___ ._.._ _..._. _.,. ______.-- --_------ <br /> www.pca.state.mn.us • 651-246-63� � 800-657-3864 • TTY 651•282-5332 or 800-657-3864 . Available in attemative formats <br /> wq-wwists4-3! . t/24/12 D,,,,a ,„s o <br />