Septic Compliance Inspection Form

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Minnesota Pollution Compliance Inspection Form Control Agency 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems St.Paul,MN 55155-4194 (SSTS) Doc Type:Compliance and Enforcement Instructions: Inspection results based on Minnesota Pollution Control Agency(MPCA) For local tracking purposes: requirements and attached forms—additional local requirements may also apply. Submit completed form to Local Unit of Government(LUG)and system owner within 15 days System Status System status on date(mm/ddlyyyy): 5/22/2018 ® Compliant— Certificate of Compliance ❑ Noncompliant— Notice of Noncompliance (Valid for 3 years from report date, unless shorter time (See Upgrade Requirements on page 3) frame outlined in Local Ordinance.) Reason(s)for noncompliance (check all applicable) ❑ Impact on Public Health (Compliance Component #1)—Imminent threat to public health and safety ❑Other Compliance Conditions(Compliance Component#3)—Imminent threat to public health and safety ❑Tank Integrity(Compliance Component #2)—Failing to protect groundwater ❑Other Compliance Conditions(Compliance Component#3)—Failing to protect groundwater ❑Soil Separation(Compliance Component #4)—Failing to protect groundwater ❑Operating permit/monitoring plan requirements(Compliance Component #5)—Noncompliant Property Information Parcel ID#or Sec/Twp/Range: 3211823420005 Property address: 300 Stubbs Bay Road N, Orono, MN Reason for inspection: Property Transfer Property owner: Tom Fleming Owner's phone: 612-991-2944 or Owner's representative: Representative phone: Local regulatory authority: City of Orono Regulatory authority phone: 952-249-4600 Approximately 2-1300 gallon septic tanks,1-1300 gallon lift station and 630 square feet of mound Brief system description: rockbed. Comments or recommendations: Two rock beds 32 feet long. Certification I hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No determination of future system performance has been nor can be made due to unknown conditions during system construction, possible abuse of the system, inadequate maintenance, or future water usage. Inspector name: Joseph J Olson Certification number: 1255 Business name: Rusty 01 on's Soil&Perc, Testing License number: 810 Inspector signature. Phone number: 763-498-8779 Necessary •(Locally Required Attachments ® Soil boring logs ❑System/As-built drawing ❑ Forms per local ordinance ❑ Other information(list): www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats wq-wwists4-31 • 1/14/11 Page 1 of 3