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7 tViinnesata Po!lution Compliance Inspection form <br /> � �� .: <br /> Cantrol Agen�y , <br /> 520 Lafayette Road North E�isting Subsurface Sewage Treatment Systems (SSTS) <br /> St.Paul,MN 55155-4194 Doc Type:Comp/iance and Enforcement <br /> � <br /> inspection results based on Minnesota Poilution Controi Agency(MPCA) For local tracking purposes: <br /> requirements and attached forms-additional local requirements may atso appfy. <br /> Submit completed form to Loca�Unit of Government(LUG)and system owner <br /> within 15 days <br /> System Status <br /> System status on date(mm/dd/yyyy): 11J19/2014 <br /> ❑ Compliant— Certificate of Compliance � Noncompliant— Notice of Noncompliance <br /> (Valid for 3 years from report date, uRless shorter Sme (See Upgrade Requiiements on page 3.) <br /> frame ouUined in Loca!Ordinance.) <br /> Reason(s)for noncompliance (check all appticable) <br /> ❑ Impact on Public Health (Comp/iance Component#1)—/mminent ti►reat to public health and safety <br /> ❑ Other Compliance Conditions(Compliance Component#3)—lmminent threat to public health and safety <br /> ❑Tank Integrity(Compliance Component#2)—Failing to protect groundwater <br /> ❑Other Compliance Condifions(C�mp/iancs Component#3)—Failing to protect groundwater <br /> �Soil Separation(Compliance Component#4)—Failing fo protect groundwater <br /> ❑ Operating permiUmonitoring plan requirements(Compliance Component#5)—Noncompliant <br /> Property Information Par�ei ia#or secrrwpiRa►,9e: <br /> Property address: 290 Hollander Road Orono, MN Reason for inspection: property transfer <br /> Property owner: ���p jj'/�,�u� Owners phone: (�/a. �,;�.- y�P,77 <br /> or <br /> Owner's representative: Jake Ehlers _� Representative phone: 612-720-4987 <br /> Local regu(atory authority: City of Orono __ Regulatory authority phone: <br /> Brief system description: 1-125p and 1-1000 septic tank 1-1250 pump tank, rock trenches <br /> Camments or recommendations: <br /> Certification <br /> 1 hereby cerfify that a/l the necessary information has been gathered to deteRnine the compliance status of this system.No <br /> dQtsrmination offuture system peiformance has been nor can bs made due to unknown co�diti�ns dunng system c�n�truction, <br /> possible abuse of the system,inad�quate maintenance, or firture wafer usage. <br /> Inspector name: Andrew Kleindf' Certification number: 7927 <br /> Business name: Jim's Excavatin LLC License number: 2926 <br /> lnspector signature: �%��� � Phone number. 952-442-9282 <br /> Necessary or Locatly Req;uired Attachments <br /> �Soil boring logs ❑System/As-built drawing ❑ Forms per local ordinance <br /> ❑ Other information(list): <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-wwists4-31b • 6/4/14 Page 1 of 3 <br />