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Mar 28 2017 1022AM HP FaxRusty Olson 7634988290 page 2 <br /> '° Minnesota Pollution Compliance Inspe�tion Form <br /> Control Agency <br /> 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems <br /> St.Paul,MN 55755-4194 (S$T$� <br /> Doc Type:Compl�ance and Enforcement <br /> Instructions: Inspection results based on Minnesota Pollution Control l�qency(MPCA) For local tracking purposes: I <br /> requirements and attached forms—additional local requirements may also apply. <br /> Submit completed form to Local Unit of Government(LUG)and system owner I <br /> within 15 days <br /> Systern Status <br /> System status on dats(mmlddlyyyy): 3120/201T <br /> � Compliant—Certifcate af Compliance ❑ Noncompliant—Notice of Noncompliance <br /> (Valid for 3 years from report date, unless sho�ter 6me (See Upg�ade Requirements on page 3) <br /> frame outlined rn Local Ordinance.) <br /> Reason{s)for nortcompliance (check all applicable) <br /> ❑ Impact on Public Health (Compliance Component #1)—Irnmrnent th�eat to public health and safety <br /> ❑Other Compliance Conditions(Compliance Component#3)—lmminent threat to public hea/th and safety <br /> ❑Tank Integrity(Compliance Component #2)—Failing to profectgroundwater <br /> ❑ Other Compliance Conditions(Compliance Component#3)—Failing to pr�tecf gmundwater <br /> ❑Sail 5eparation(Compliance Component #4)—Failing to protecf grourrdwater <br /> ❑ Operating permiUmonitoring plan requirements(Complrance Component #5)—Noncomp/ianf <br /> Property Information Parcel !D#or SeGTwplRange: 2i118234100�2 <br /> Property address: 1805 Sixth Ave. N., Orono, MN Reason ior inspection: Property Transfer <br /> Property owner: Laurent Migault _ Owner's phone: 612-216�646 <br /> or - <br /> Owner's representative: Representative phone: _ <br /> Locaf regulatory authority: City of Orono Regulatory authoriry phone: 952-249-4600 <br /> Approximafely 2-1300 gallon septic tanks,1-1500 gallon lift station and 780 square ieet of mound <br /> Brief system description: rockbed. <br /> Comments or recommendations: <br /> Certification <br /> !hereby certify that all the necessary informa6on has been gathered to determine the compliance status of this system.No <br /> determination of fufure system performance has been nor can be made due to unknown conditions during system consfruction, <br /> possible abuse of the system, inadequate maintenance, or future water usage. <br /> Inspector name: Jose h J plson Certification number: 1255 <br /> Business name: Rust Qlson's Soil&Perc.Testin License number: 810 <br /> Inspector signature: Phone number: 763�98-8779 <br /> Necessary or LocalEy Required Attachments <br /> � Soil boring logs ❑System/As-built drawing ❑ Forms per loca!ordinance <br /> ❑Other information (list): <br /> www.pca.5tate.mn.us • 651-296-6300 • 800-657-3864 • TTY b51-282-5332 or 800-657•3864 • Avallable in altemative formats <br /> wq-ww�sts4-3! . !l24lf? Page t of3 <br />