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Apr 17 15 09:59a Joseph Olson 763-498-8290 p.2 <br /> Minnesota Pollutior� Complia�ce I�spection Form <br /> CantroE Agency <br /> S20 Lafayette Road Idorth Existing Subsurtaae Sewage Treatment Systems <br /> 5L Paut,MN 55155-4194 ($STS� <br /> Doc 7ype:CompGanoe and Enfa�ement <br /> Instructions: Inspection results based on Minnesota Pollution Corriroi Agency(MPCA) �or local tracking purposes: <br /> requi�ements and attadie�forms-additfonaa�ocaa requirements may a�so app�y. APR � � ZO�5 I <br /> Submit completed form to Local Unit of Governmerrt(LUG)and syst�em owne� <br /> within 15 days <br /> System Status <br /> Sys�em status on date(mm/ddlyyyy): 4H 3/2�15 <br /> � Coinpiiant—Certifcate of Compliance ❑ Noncompliant—Notice of IVoncompliance <br /> (Valid for3 years from re�orf dafe,unless shwter time (See Upgrade Requinements on page 3) <br /> frame ouftined in Loca1 Ordinance.) <br /> Reason(s)for noncompliance(check aIl applicabfe) <br /> ❑Impact on Public Health(Compliance Component #i)—Imminenf ihreat to pu�c heafth and safe(y <br /> ❑ Other Compfiance Condiiions(Compliance Cornponent#3)—Imminent threat to public health ar►d safety <br /> ❑Tank Integrify(Compfiance Component #2)—Fa�ing to protect groundwater <br /> ❑Other Compliance Conditior�s(Compliance Component#3)—Fairng to profect grounorwater <br /> ❑Soii Separation(Compliarrce Component #4)—Failing to protect grocrnafwater <br /> ❑Operating permitlmonitoring plan requirements(Compliance Componenf #5)—Noncompliant <br /> Property Information Parcel ID#or Serlfwp/Range: 3611823330009 <br /> Properry address: 10 Myrtlewood Road,Orono,MN Rea�n for inspeciion: Property 7ransfer <br /> Property owner: Bryan Freeland Qwners phone: <br /> or <br /> Owner's representative: Gregg Larsen Representative ph�ne: 612-719-4477 <br /> Lacal regulatory authprity: �of Orono Regulatory aufhority phone: 952-249-4600 <br /> 2-1000 gallon septic tanks,l-7Q00 gallon lift station and 380 square feet of mound roctcbed. per aty <br /> Brief system descripUon: records <br /> Comments or recommendations: <br /> Certification <br /> I here6y certily that alJ the necessary information has been gathered to determine the compliance stafus of fhis sys[em.Ab <br /> determination of futwe system perfom�a�rcae has been nor can be made due to unlmown condiGons during system oonstruction, <br /> possibfe abuse of the system,inadequate mainte»ance, or future water usage. <br /> Inspector name: Joseph J Olson Certification nurnber: 1255 <br /> Business name: Rus O 's Soil 8� �'estin Lice�se number. 810 <br /> Inspector signature: Phone number: 763-498-8779 <br /> Necessary o� L.ocally Required Attachrnents <br /> � Soil boriRg iags � System/As-built drawing ❑Forms per local ordinance <br /> ❑ Other information(list): <br /> v�rnw_pca.state.mn.us • 651-z96•6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats <br /> wq-wwisGs4-3i • 1124/11 Page 1 of 3 <br />