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Minnesota Po1{ution Compliance Inspection Form <br /> Control Agency <br /> szo�3fay��ce Ro�d No�tf, Existing Subsurface Sewage Treatment Systems (SSTS) <br /> St.Paul,MN 55155 4194 Doc Type:Complrance and Enlorcement <br /> _ _ <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 /> $)/StE'I'Tl $tdtUS <br /> System status on date(mm/dd/yyyy): 7/28/2016 <br /> � Compliant — Certificate of Compliance ❑ Noncompliant— Notice of Noncompliance <br /> (Valid tor 3 years from report date, unless shorter trme (See Upgrade Requirements on page 3.) <br /> frame outlined i�1 Loca!Ordinance.) <br /> Reason(s)for noncompliance (check all applicable) <br /> ❑ Impact on Public Health (Compliance Component#1)-lmminent threat to public health and safety <br /> ❑ Other Compliance Conditions (Compfiance Component#3)-Immrnent threat to publrc health and safety <br /> ❑ Tank Integrity(Complrance Component#2)-Failing to protecf groundwater <br /> ❑ Other Compliance Conditions(Complrance Component#3)-Failing to protect groundwafer <br /> ❑ Soil Separation (Compliance Component#4)-Failir�g to protect groundwater <br /> ❑ Operating permiUmonitoring plan requirements(Compliance Component#5)-Noncompliant <br /> Property Information Parcel ID#or Sec/Twp/Range: <br /> . _ _ ___ <br /> Property address: 1200 Phillips Dr. Orono,Mn 55356 Reason for inspection: Sale <br /> _ _ . _ _ . <br /> . _.. . _.. _. <br /> Property owner: Ned Dau Owner's phone: 612-280-8119 <br /> _. <br /> _ _ ___ ___ __ _. <br /> or _ __. <br /> Owner's representative: Representative phone: <br /> _ _ <br /> Local regulafory authority: Regulatory authority phone: <br /> __ <br /> _ __ <br /> _ __ <br /> Brief system description: 5 bedroom Mound System <br /> _ __ __ <br /> Comments or recommendations: <br /> system has 12"of cover over the top. It is recommended that grass be planted over the mound system. <br /> Certification <br /> 1 hereby certi(y thaf a!I the necessary information has been gathered to determine the compliance stafus of fhis system. No <br /> determinatron of future sysiem performance has been nor can be made due to unknown conditions during system construction, <br /> possrble abuse o(the system. rnadequate maintenance, or future water usage. <br /> Inspector name: Josh Swedfund Certification number. C1659 <br /> Business name: Swedlund Septic�\e License number: 2502 <br /> Inspector signature: �� Phone number: 952-873-3292 <br /> Necessary or Localty Required Attachments <br /> � Soil boring logs � System/As-built drawing ❑ Forms per local ordinance <br /> ❑ Other information(list): <br /> __ <br /> www.pca.state.mn.us • 651-296•6300 • 800-657-3864 • 1TY 651-282-5332 or 800-657-3864 • Available in atternative formats <br /> wq-wwists4-31 • 3/16/12 Page t oJ 3 <br />