Certificate of Compliance_1180 Homestead Trail_6-5-19

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Page 1 of 3 Certificate of Compliance Inspection Form New Subsurface Sewage Treatment Systems (SSTS) Noncompliant – Notice of Noncompliance (See Upgrade Requirements on page 3.) Impact on Public Health (Compliance Component #1) – Imminent threat to public health and safety Other Compliance Conditions (Compliance Component #3) – Imminent threat to public health and safety Tank Integrity (Compliance Component #2) – Failing to protect groundwater Other Compliance Conditions (Compliance Component #3) – Failing to protect groundwater Soil Separation (Compliance Component #4) – Failing to protect groundwater Operating permit/monitoring plan requirements (Compliance Component #5) – Noncompliant Parcel ID# or Sec/Twp/Range: Reason for inspection: Owner’s phone: Representative phone: Regulatory authority phone: Property Information Property address: Property owner: or Owner’s representative: Local regulatory authority: Brief system description: Comments orrecommendations: Certification I hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No determination of future system performance has been nor can be made due to unknown conditions during system construction, possible abuse of the system, inadequate maintenance, or future water usage. Certification number: License number: Phone number: Inspector name: Business name: Inspector signature: Necessary or Locally Required Attachments Soil boring logs System/As-built drawing Other information (list): Inspection results based on Minnesota Pollution Control Agency (MPCA) requirements and attached forms System status on date 06/05/2019: Compliant – Certificate of Compliance Valid for 5 years from report date Reason(s) for noncompliance (check all applicable) X 1180 Homestead Trail New Istallation Jake Carlson 763-229-2515 City of Orono 952-249-4600 Roger Peitso Type I mound #C6683 952-249-4625 X X