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• <br /> otAk <br /> ,; gi Minnesota Pollution Compliance Inspection Form <br /> Control 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): 10/2/2017 <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 health 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 permit/monitoring plan requirements(Compliance Component#5)—Noncompliant <br /> Property Information Parcel ID#or Sec/Twp/Range: <br /> Property address: 2820 Der Run Trail-Orono Reason for inspection: Sale <br /> Property owner: Kelly Dillon _ Owner's phone: 651-274-0546 <br /> or <br /> Owner's representative: Representative phone: <br /> Local regulatory authority: City Regulatory authority phone: <br /> Brief system description: 1250 gal septic, 1000 gal septic& 1250 pump tank,mound system <br /> Comments or recommendations: <br /> Certification <br /> I hereby certify 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 during system construction, <br /> possible abuse of the system,inadequate maintenance,or future water usage. <br /> Inspector name: Josh Swedlund _ Certification number: C1659 <br /> Business name: Swedlun• -ptic ice; / License number: 2502 _ <br /> Inspector signature: ��/'. i Phone number: 952-873-3292 <br /> Necessary or Locally Required Attachments <br /> ®Soil boring logs ® System/As-built drawing ® Forms per local ordinance <br /> 0 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 • 3/16/12 Page 1 of 3 <br />