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Page 1 of 3 <br />Certificate of Compliance <br />Inspection Form <br />New Subsurface Sewage <br />Treatment Systems (SSTS) <br /> Noncompliant – Notice of Noncompliance <br />(See Upgrade Requirements on page 3.) <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 />Parcel ID# or Sec/Twp/Range: <br />Reason for inspection: <br />Owner’s phone: <br />Representative phone: <br />Regulatory authority phone: <br />Property Information <br />Property address: 4154 Deborah Drive <br />Property owner: <br />or <br />Owner’s representative: Kevin Barthel <br />Local regulatory authority: City of Orono <br />Brief system description: Comments orrecommendations: <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 />Certification number: <br />License number: <br />Phone number: <br />Inspector name: <br />Business name: <br />Inspector signature: <br />Necessary or Locally Required Attachments <br /> Soil boring logs System/As-built drawing <br /> Other information (list): <br />Compliant – Certificate of Compliance <br />Valid for 5 years from report date <br />Reason(s) for noncompliance (check all applicable) <br />X <br />New instalation <br /> 612-919-0112 <br />952-249-4600 <br />Roger Peitso C6683 <br />952-249-4625 <br />X X <br />Inspection results based on Minnesota Pollution Control Agency (MPCA) requirements and <br />attached forms System status on date ________________:06/15/2020