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Jan 09 2017 01:07PM HP FaxRusty Olson 7634988290 page 2 <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 Type:Compliance and Enforcement <br /> RECEIVED <br /> Instructions: Inspection results based on Minnesota Pollution Control Agency(MPCA) ! For local tracking purposes: <br /> requirements and attached forms-additional local requirements may also apply. JAN 0 y 2017 <br /> Submit completed form to Local Unit of Government(LUG)and system owner ' <br /> within 15 days <br /> CITY OF ORONO <br /> System Status <br /> System status on date(mmlddlyyyy): 116/2017 <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 /> 0 Impact on Public Health(Compliance Component #1)-Imminent threat to public health and safety <br /> ❑Other Compliance Conditions(Compliance Component#3)-Imminent threat to public health and safety <br /> El 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 114)-Failing to protect groundwater <br /> ❑Operating permit/monitoring plan requirements(Compliance Component #5)-Noncompliant <br /> Property Information Parcel ID#or Secfrwp/Range: 0411723420016 <br /> Property address: 2 White Oak Circle.,Orono,MN Reason for inspection: Property Transfer <br /> Property owner: atrick Doherty Owner's phone: <br /> or <br /> Owner's representative: Mimi Ryerse Representative phone: 612-280-8284 <br /> Local regulatory authority: City of Orono Regulatory authority phone: 952-249-4600 <br /> 1-2250 gallon septic tank,1-1000 gallon lift station and 500 square feet of mound rockbed.per city <br /> Brief system description: records <br /> Comments or recommendations: <br /> Certification <br /> 1 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: Joseph J Olson Certification number: 1255 <br /> Business name: Rusty O n's Soil&Perc.Testing License number: 810 <br /> Inspector signature: Phone number: 763-498-8779 <br /> Necessary r/Locally Required Attachments <br /> ®Soil boring logs ®System/As-built drawing ❑ Forms per local ordinance <br /> 0 Other information(list): <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-wwists4-31 • 1/24/12 Page 1 of 3 <br />