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� <br /> . q� <br /> , ���r�� Minnesota Pollution COI'1'1�J�1dI�1Ce �I'1S�JeCt1011 FOI"1'1'1 <br /> • � Con#ral Agency <br /> 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems (SSTS) <br /> St.Paul,MN 55155-4194 Doc Type:Compliance and Enforcement <br /> InspeCtion results based on Minnesota Pollution Control Agency(MPCA) 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(mm/dd/yyyy): 7/20/2017 <br /> � Compliant— Certificate of Compliance ❑ Noncompliant— Notice of Noncompliance <br /> (Valid for 3 years from report date, unless shorter time (See Upgrade Requirements on page 3.) <br /> frame outlined in Local Ordinance.) <br /> Reason(s)for noncompliance (check all applicable) <br /> ❑ Impact on Public Health (Compliance Component#1)—Imminent threat to public hea/th 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 permiUmonitoring plan requirements (Compliance Component#5)—Noncompliant <br /> Property Information Parcel ID#or Sec/Twp/Range: <br /> Property address: 1070 Hunter Drive Reason for inspection: New Installation <br /> Property owner: Owner's phone: <br /> or <br /> Owner's representative: Bohn Well Drilling Commpany Representative phone: 612-919-1540 <br /> Local regulatory authority: City of Orono Regulatory authority phone: 952-249-4600 <br /> Brief system description: Mound <br /> Comments or recommendations: <br /> New Installation <br /> Certification <br /> 1 hereby ce►tify 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 dunng system construction, <br /> possib/e abuse of the system, inadequate maintenance, or future water usage. <br /> Inspector name: Roger Peitso Certification number: #6683 <br /> Business name: License number: <br /> Inspector signature: Phone number: 952-249-4625 <br /> Necessary or Locally Required Attachments <br /> ❑ Soil boring �ogs ❑ System/As-built drawing ❑ Forms per local 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-wwists4-316 • 6/4/14 Page 1 of 3 <br />