12-06-19 Septic Compliance Form - Laserfiche WebLink

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Minnesota Pollution compliance Inspection Form Control Agency 524 Lafayette Road North Existing Subsurface Sewage Treatment Systems 5t. Paul, MN 55155-4194 (SSTS) Doc Type: Compliance and Enforcement Instructions: Inspection results based on Minnesota Pollution Control Agency (MPGA) 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 (mmlddlyyyy): 121612019 ® 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 SeclTwp/Range: 1111723230015 Property address: 1510 Green Trees Road, Orono_, MIS Reason for inspection: Property Transfer Property owner: Scott Stevenson Owner's phone: 612-437-9273 or Owner's representative: Gregg Larsen Representative phone: 612-719-4477 Local regulatory authority: City of Orono Regulatory authority phone: 952-249-4600 Brief system description: 2-1000 and 880 square feet of Trench. per city records Comments or recommendations: TBM: Top of the basement door threshold BL- 100.0 assumed 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: RustOlson's Soil & Perc. Testing Inspector signature: Necessary or Locally Required Attachments License number: 810 Phone number: 763-498-8779 Z 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 • 1124112 PoSe 1 of 3