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��=� Minnesota Poliution Compliance Inspection Form <br /> �' '' Control Agency <br /> 520 Lafayette Road North Existing Sabsurface Sewage Treatment Systems (SSTS) <br /> St Paul,MN 55155-4194 Doc Type:Compliance and Enforcement <br /> InspeCtion �esults based on Minnesota Potivaon Control Agency(MPCA) For local tracking purposes: <br /> requirements and attached forms—additional local requirements may also apply. R���-� �"''1 <br /> �. <br /> Submit completed form to Local Unit of Govemment(LUGf and system owner <br /> within 15 days <br /> System Status �ITY OF OROf�O <br /> System status on date(mmlddlyyyy): 9/25/2014 <br /> � Compliant-Certificate of Compliance ❑ Noncompliant- Notice of Noncompliance <br /> (Valid for 3 years from�port date, unless shorter time (See Upgrade Requirements on page 3.) <br /> frame outlined in Locaf Ordinance.) <br /> Reason(s)for noncompfiance(check all applicable) <br /> ❑ Impact on Public Health (Compliance Component#1)—lmminent threat to public health and safety <br /> ❑ Other Compliance Conditions(Compliance Component#3)—Imminent thneat to public health and safety <br /> ❑Tank Integrity(Compliance Componenf#2)—Failing to prr�tect grr�undwater <br /> ❑Other Comp{iance Conditions(Compliance Component#3}—Failing to piotect groundwafer <br /> ❑Soil Separation(Compliance Component#4)—Failing fo protect groundwater <br /> ❑Operating permiUmonitoring plan requirements(Compliance Component#5)—Noncompliant <br /> Property fnformation Parcel ID#or SeclT'wp/Range: <br /> Property address: 645 Ferndale Road, Orono,MN Reason for inspection: property transfer <br /> Property owner: Tom Page Owner's phone: _ <br /> or <br /> Owners representa#ive: Representative phone: <br /> Local regulatory authority: �of Orono Regulatory authority phone: <br /> Brief system description: 2-1000 septic tank 1-1000 pump tank mound treatment with 10ftX50ft rockbed __ <br /> Comments or recommendations: <br /> Certification <br /> I hereby certify that all fhe necessary infonnafion has been gathe�d to determine the compliance status of fhis system. No <br /> determination of future system perfom►ance has been nor can be made due to unknown condifions during sysfem construction, <br /> possible abuse of fhe system,in�dequafe maintenance, or futuie wafer usage. <br /> Inspector name: Andrew Kleindl ____ Certification number: 7927 <br /> Business name: Jim's Excavatin LLC . License number: 2926 <br /> Inspector signature: _ Phone number: 952-4442-9282 <br /> Necessary or Localty Required Attachments <br /> �Soil boring logs ❑ System/As-built drawing ❑ Forms per local ordinance <br /> ❑Other information(tist): <br /> www.pca.state.mn.us • 651-296-b300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in altemative formats <br /> wq-wwfists4-31b • 6/4/14 Page 1 of 3 <br />