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Jun 05 2C 6 09:30AM HP FaxRusty Olson 7634988290 page 2 <br /> 441 <br /> Minnesota Pollution Compliance Inspection Form <br /> Control Agency P P <br /> 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems <br /> St.Paul,MN 55155-4194 (SSTS) <br /> Doc Typo:Compliance and Enforcement <br /> Instructions: Inspection results based on Minnesota Pollution Control Agency(MPCA) : For local trfiltt v ED <br /> requirements and attached forms-additional local requirements may also apply. 1+G1 v <br /> Submit completed form to Local Unit of Government(LUG)and system owner JUN n 6 ?016 <br /> within 15 days - <br /> System Status CITY OF ORONO <br /> System status on date(mmldd/yyyy): 5/31/2016 <br /> Z 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 ID#or Sec/Twp/Range: 33-118-23-34-0013 <br /> Property address: 155 Wear Lane.,Orono,MN Reason for inspection: Property Transfer <br /> Property owner: Catherine Wersal Owner's phone: -612-597-6661 <br /> or <br /> Owner's representative: Representative phone: <br /> Local regulatory authority: City of Orono Regulatory authority phone: 952-249-4600 <br /> 2-1000 gallon septic tanks,1-1000 gallon lift station and 500 square feet of mound rockbed. per city <br /> Brief system description: records <br /> Comments or recommendations: <br /> Certification <br /> I 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 Olson's Soil&Perc,Testing License number: 810 <br /> Inspector signature: ;r�'"� � <br /> Phone number: 763-496-8779 <br /> Necessary dr Locally Required Attachments <br /> El Soil boring logs ®System/As-built drawing El Forms per local ordinance <br /> ❑ Other information(list): <br /> www.pca.s:ate.mn.us • 651-296-6300 • 800-657-3864 • TTY 651.282-5332 or 800.657.3864 • Available in alternative formats <br /> wq-wwists4-31 • 1124/12 <br /> Page 1 of 3 <br />