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Minn=:: ,utionllCompliance Inspection Form <br /> Contt <br /> 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems <br /> St.Paul,MN 55155-4194 (SSTS) <br /> Doc Type Compliance and Enforcement <br /> Instructions: Inspection results based on Minnesota Pollution Control Agency(MPCA) For local tracking purposes: <br /> requirements and attached forms–additional local requirements may also apply. <br /> Submit completed form to Local Unit of Government(LUG)and system owner <br /> within 15 days <br /> System Status <br /> System status on date(mm/dd/yyyy): 11/2612017 <br /> CI Compliant—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 /> frame outlined in Local Ordinance.) <br /> Reason(s)for noncompliance(check all applicable) <br /> ❑Impact on Public Health(Compliance Component #1)–Imminent threat to public health and safety <br /> ❑Other Compliance Conditions(Compliance Component#3)–Imminent threat to public health and safety <br /> ❑Tank Integrity(Compliance Component #2)–Failing to protect groundwater <br /> ❑Other Compliance Conditions(Compliance Component#3)–Failing to protect groundwater <br /> ❑Soil Separation(Compliance Component #4)–Failing to protect groundwater <br /> ❑Operating permit/monitoring plan requirements(Compliance Component #5)–Noncompliant <br /> Property Information Parcel 1D#or Sec/Twp/Range: 0911723210001 _ <br /> Property address: 825 Old Crystal Bay Road S.,Orono,MN _ Reason for inspection: Property Transfer <br /> Property owner: Judson Dayton Owner's phone: – <br /> — ..._ <br /> or <br /> Owner's representative: George Stickney Representative phone: 952-250-1075 <br /> Local regulatory authority: City of Orono Regulatory authority phone: 952-249-4600 <br /> 2-1500 gallon septic tanks.1-1500 gallon lift station and 550 square feet of mound rockbed.per city <br /> Brief system descriptbn: records <br /> Comments or recommendations: <br /> Certification <br /> 1 hereby certify that all the necessary information has been gathered to determine the compliance status of this system No <br /> determination of future system performance has been nor can be made due to unknown conditions during system construction, <br /> possible abuse of the system,inadequate maintenance, or future water usage. <br /> Inspector name: Joseph J Olson Certification number: 1255 _ <br /> Business name: Rusty 0 s Soil&Perc.Testing License number 810 ^ <br /> Inspector signature: Phone number: 763-498-8779 <br /> Necessary ocally Required Attachments <br /> ® Soil boring logs ®System/As-built drawing 0 Forms per local ordinance <br /> 0 Other information(fist): <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651.282.5332 or 800-657-3864 • Available in alternative formats <br /> wq-wwists4.31 • 1/24/12 <br /> Page 1 of 3 <br />