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Feb 22, 2016 04:35PM HP FaxRusty Olson 7634988290 page 2 <br /> MinnesotaPollution Compliance Inspection Form <br /> Cantrol Agency <br /> 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems <br /> St.Paul,MN 55t 55-4194 ($ST$� <br /> Doc Type:Compliance and Enior�ement <br /> lnsiructions: Inspection resuits based on Minnesota Pollution Control Agency(MPCA) j �or lacal tracking Rurposes: <br /> requirements and attached forms-additional local requirements may also apply. I FE6 2 2 2016 <br /> Submit completed form to Local Unit of Government(LUG)and system owner <br /> within 15 days ' <br /> System Status <br /> Sysbem status on date(mmldd/yyyy�: 2J20/2016 <br /> � Campliant—Ce�tificate of Compliance ❑ Noncornpliant— Notice af Noncompliance <br /> (Valid for 3 years from�eport date, unless shorter time (See Upgrade Requrrements on page 3) <br /> frai»e outlined in toca!Ordinance.) <br /> Reason(s)tor noncompliance (check alf applicable) <br /> ❑ Impact on Public Health (Compliance Component #1}-lmminent fhreaf to public health and safety <br /> ❑Other Compliance Conditions(Compliance Component#3)-Imminentthreat to public health and safety <br /> ❑Tank Integrity(Gompliance Component #2)-Failing to protectgroundwater <br /> ❑Other Compliance Conditions(Complrance Component#3)-Failing to protect groundwater <br /> ❑Soil Separation (Compliance Component #4)-Failing to prorect groundwater <br /> ❑ Operating permiUmonitoring plan requirements(Compliance Component #5)-Noncompliant <br /> Property Information Parcel ID#or SeclTwplRange: 04-117-23-34-0003 <br /> Property address: 2811 Fairview Lane, Orono, MN Reason for inspection: Property Transfer <br /> Property owner: Kate Tabner Owner's phone: 917-864-6666 <br /> or <br /> Owners representative Representative phone: <br /> Local regulatory authariiy� City of Orono Regulatory authority phone: 952-249-4600 <br /> 2-1Q00 gallon septic tanks,l-1000 gallon lift station and 500 squa�e feet of mound rockbed, per city <br /> Brief system description: records <br /> Comments or recommendations: <br /> Certification <br /> !hereby certify that al!the necessary informat�"on has been gafhered to determine the compliance status of thrs system. No <br /> determination of future system performance has been nor can be made due to unknown conditions dunng system construction, <br /> possiWe abuse of the system,inadequate marntenance, orfufure waterusage. <br /> Inspector name: Joseph J Olson Certification number: 1255 <br /> Business name: Rust son's Soil&Perc.7estin License number: 810 <br /> Inspector signature: _ Phone number: 763-498-8779 <br /> Necessary or ocally Required Attachments <br /> � Soil boring logs � System/As-built drawing ❑ Forms per(ocal 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-wwists4•31 • f/24/12 Page 1 of 3 <br />