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Apr 20 15 06:17p Joseph Olson 763-498-8290 p.9 <br /> Minnesota Pollution Compliance Inspection Form <br /> Control Agency <br /> 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems <br /> St.Paul,MN 55155-4194 (SSTS) <br /> Doc T}rpe omplience and Enforcement <br /> KK cCIVED <br /> Instructions: inspection results based on Minnesota Pollution Control Agency(MPGA) For local frac in purposes: <br /> requirements and attached forms-additional local requirements may also apply. APR 212015 <br /> Submit completed form to Local Unit of Government(LUG)and system owner c" <br /> within 15 days OF ORONO <br /> System Status <br /> System status on date(mmldd/yyyy): 4/16/2015 <br /> Compliant-Certificate of Compliance ❑ Noncompliant- Notice of 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 safely <br /> ❑Other Compliance Conditions(Compliance Component#3)-Imminent threat to public health and safety <br /> ❑Tank Integrity(Compliance Component #2)-Failing to protect groundwater <br /> ❑ Other Compliance Conditions(Compliance Component#3)-Failing to protect groundwater <br /> ❑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/Two/Range: 0411723420014 <br /> Property address: 2785 White Oak Circle, Orono,MN Reason for inspection: Property Transfer <br /> Property owner: John Dougan Owner's phone: 952-473-0355 <br /> or <br /> Owner's representative: Representative phone: <br /> Local regulatory authority: City of Orono Regulatory authority phone: 952-249-4600 <br /> 2-1000 gallon septic tanks,1-1000 gallon lift station and 380 square feet of mound rockbed. per city <br /> Brief system description: records <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 /> Inspectorname: Joseph J Olson Certification number: 1255 <br /> Business name: Rus on's Soil&Perc.Testing License number: 810 <br /> Inspectorsignatur - <br /> --�" Phone number: 763-498-8779 <br /> Necessary or Locally Required Attachments <br /> ® Soil boring logs 0 System/As-built drawing ❑Forms per local ordinance <br /> ❑Other information (list): <br /> www.pca.state.mn.us • 651-246-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats <br /> wq-wwists4-31 + 1124/12 Page 1 of 3 <br />