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Minnesota Pollution Compliance Inspection Form <br /> Control Agency <br /> 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems <br /> V <br /> (� ql St.Paul,MN 55155-4194 (SSTS) <br /> Doc Type:Compliance and Enforcement <br /> Instructions: Inspection results based on Minnesota Pollution Control Agency(MPGA) For local tracking purposes: <br /> requirements and attached forms—additional local requirements may also apply. <br /> NO �/ Submit completed form to Local Unit of Government(LUG)and system owner <br /> within 15 days <br /> ystem Status <br /> System status on date mm/d <br /> ( \ �1 ( dlyyyy): 7!30!2012 <br /> C( ®Compliant—Certificate of Compliance ❑Noncompliant—Notice of Noncompliance <br /> \ l (Valid for years from report date,unless shorter time (See Upgrade Requirements on page 3) <br /> v J \ frame outlined in Local Ordinance.) <br /> Reason(s)for noncompliance(check all applicable) <br /> 0 Impact on Public Health(Compliance Component#1)—Imminent threat to public health and safety <br /> po ❑Other Compliance Conditions(Compliance Component#3)—Imminent threat to public health and safety <br /> ❑Tank Integrity(Compliance Component#2)—Farling to protect groundwater <br /> ❑Other Compliance Conditions(Compliance Component#3)—Faiing 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 l or Sec/Twp/Range: 3311823410004 <br /> Property address: 2400 Woodhaven Drive.,Orono.MN Reason for inspection: Property Transfer <br /> Property owner. Tor Aasheim Owner's phone: <br /> or <br /> Owner's representative: Mimi Ryerse Representative phone: 952-475-4913 <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 380 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 son's Soil&Parc.Testing License number. 810 <br /> Inspectorsignaturee,, —�,� Phone number. 763-498-8779 <br /> Necessary or Locally Required Attachments <br /> ®Soil boring logs ®System/As-built drawing ❑Forms per local ordinance <br /> 0 Other information(list): <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-262-5332 or 800-657-3854 - Available in alternative formats <br /> wq-wwists4-31 • 1/24/12 <br /> Page l of 3 <br />