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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 /> 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. <br /> Submit completed form to Local Unit of Government(LUG)and system owner <br /> within 15 days <br /> System Status <br /> System status on date(mm/ddlyyyy): 4/22/2017 <br /> Z 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 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 /> 0 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: 2611823410003 <br /> Property address: 1101 Willowbrook Drive.,Orono, MN Reason for inspection: Property Transfer <br /> Property owner: Lucia Delaney Owner's phone: 952-451-1799 <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 550 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 /> inspector name: Joseph J Olson Certification number: 1255 <br /> Business name: Rusty 0 n's Soil&Pero.Testing License number: 810 <br /> Inspector signature: Phone number: 763-498-8779 <br /> Necessary Locally Required Attachments <br /> El Soil boring logs ►Z4 System/As-built drawing 0 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 a.,,. ! .s7 <br />