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7 4I5— petfie__., Eaoe <br /> Minnesota Pollution ComplianceInspection Form <br /> Control Agency <br /> 520 Lafayette Road NorthExisting Subsurface Sewage Treatment Systems (SSTS) <br /> St.Paul,MN 55155-4194 Doc Type:Compliance and Enforcement <br /> Inspection results based on Minnesota Pollution Control Agency(MPCA) For local tracking purposes: I <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 I i <br /> System Status <br /> System status on date(mmidd/yyyy): 1/12/2015 <br /> 0 Compliant—Certificate of Compliance ►1 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 <br /> p y Parcel ID#or Sec/Twp/Range: ,..._218.-000..-03400 <br /> Property address: 14308 70t street SW,Cokato MN 55321 Reason for inspection: title transfer <br /> Property owner: Nancy Mattilla Owner's hone: <br /> or <br /> Owner's representative: Representative phone: <br /> Local regulatory authority: Wright County Regulatory authority phone: ._. ^_ <br /> Brief system description: tank and driainfield <br /> Comments or recommendations: <br /> in ground system soil boring indicates redox at 28 inches. Not possible for an in ground system to have vertical seperation. <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: Tim Kinney ___ .._..___..-._____..__.._.._......_.............................................. .._.__._........ Certification number: 5014 <br /> Business name: A and T_Septic License number: 1608_ _ <br /> Inspector signature: _ 1 C-_.- — Phone number: / 7j'" j <br /> Necessary or Locally Required Attachments <br /> Z4 Soil boring logs El System/As-built drawing 0 Forms per local ordinance <br /> ❑ Other information(list): <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°3lb • 6/4/14 Page 1 of 3 <br />