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Minnesota Pollution Compliance Inspection Form <br />Control Agency <br />520 Lafayette Road North Existing Subsurface Sewage Treatment Systems <br />5t. 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 />Submit completed form to Local Unit of Government (LUG) and system owner <br />within 15 days <br />System Status <br />System status on date (mmlddlyyyy): 1/25/2021 <br />® Compliant — Certificate of Compliance <br />(Valid for 3 years from report date, unless shorter time <br />frame outlined in Local Ordinance.) <br />Reason(s) for noncompliance (check all applicable) <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 />Property Information Parcel ID# or Sec/Twp/Range: 3011823330005 _ <br />Property address: 4680 Creekwood Trail, Orono, MN Reason for inspection: Property Transfer <br />Property owner: Dale <br />or <br />Owner's representative: <br />Owner's phone: 972-768-4488 <br />Representative phone: <br />Local regulatory authority: _City of Orono Regulatory authority phone: 952-249-4600 _ <br />Approximately 1-2250 gallon septic tank,1-1250 gallon lift station and approximately 630 square feet of <br />Brief system description: _mound rockbed. <br />Comments or recommendations: <br />TEM: Top of the garage concrete slab. The rock bed has 1.0 feet of sand under it on the East side and 2.1 on the West side. The <br />rock bed meets the 2.55 foot separation requirements. <br />The septic tanks and lift station were replaced and are new. <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 <br />Business name: Rusty Olsgn's Soil & Pere. Testing <br />Inspector signature: <br />Necessary or Locally Required Attachments <br />Certification number: 1255 <br />License number: 810 <br />Phone number: 763-498-8779 <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 806.657-3864 TTY 651-282-5332 or 800-657.3864 • Available in alternative formats <br />wq-wwists4-31 • 1124112 Page 1 of 3 <br />