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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) <br /> For local tracking pu <br /> requirements and attached forms-additional local requirements may also apply. APR 3 O 2015 <br /> Submit completed form to Local Unit of Government(LUG)and system owner i� <br /> within 15 days <br /> System Status <br /> System status on date <br /> (mmldd/yyyy): 04/28/2015 <br /> ❑ Compliant—Certificate of Compliance {❑ Noncompliant—Notice of <br /> 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 /> 0 Other Compliance Conditions(Compliance Component#3)-Imminent threat to public health and safety <br /> ❑Tank Integrity(Compliance Component#2)-Failing to protect groundwater <br /> 0 Other Compliance Conditions(Compliance Component#3)-Failing to protect groundwater <br /> ►,1 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 <br /> address: 20 Wear Lane S Orono,MN Reason for inspection: Sale <br /> Property owner: Gerald Krepps Owner's phone: 612-619-7159 <br /> or <br /> Owner's representative: Self Representative phone: _Same as above <br /> Regulatory authority <br /> Local regulatory authority: City of Orono phone: 952-249-4600 <br /> Brief system description: 2-1000 gal tanks,to a 1000 gal lift station to 4-gravity trenches <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: Brad Krotzer Certification number 1744 <br /> Business name: Custom Septic,Inc License number: 3436 <br /> Inspector signature: �� ----- Phone number: 763-218-4769 <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-wwlsts4-3lb • 6/4/14 Page 1 of 4 <br />