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OA Minnesota Pollution Compliance Inspection Form <br />Control Agency <br />Control <br />Road North Existing 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: <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): 2/6/2020 <br />® 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 permittmonitoring plan requirements (Compliance Component #5) — Noncompliant <br />Property Information <br />Parcel ID# or Sec/Twp/Range: <br />Property address: 515 Ferndale Road North, Orono Reason for inspection: <br />Sale <br />Property owner: Clark Gassen Owner's phone: 612-720-0456 <br />or <br />Owner's representative: <br />Local regulatory authority: <br />Of <br />Representative phone: <br />Regulatory authority phone: <br />Brief system description: 2 -1500 gal septic & 1500 gal pump tank with a mound system. large effluent filter in 2n° tank <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: Josh SwedlundCertification number: C1659 <br />Business name: Sewer Servi c.41 License number: 2502 <br />Inspector signature: Phone number: 952-873-3292 <br />Necessary or Locall Required Attachments <br />® Soil boring logs ® System/As-built drawing ® 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-ww1sts4-31 • 3116112 Page 1 of 3 <br />