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Mailing Address Street Address Certificate of Compliance <br />P.O. Box 66 2750 Kelly Parkway <br />Crystal Bay, MN 55323 Orono, MN 55356 Inspection Form <br />y� N Phone: 952-249-4600 Fax: 952-249-4616 <br />���csno�ti website: www.ci.orono.mn.us New Subsurface Sewage <br />Treatment Systems (SSTS) <br />Inspection results based on Minnesota Pollution Control Agency (MPCA) requirements <br />and attached forms System status on date 05/28/2020 <br />Compliant —Certificate of Compliance <br />Valid for 5 years from report date <br />Reason(s) for noncompliance (check all applicable) <br />❑ Noncompliant — Notice of Noncompliance <br />(See Upgrade Requirements on page 3.) <br />❑ 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 />❑ 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 <br />Parcel ID# or Sec/Twp/Range: <br />Property address: 545 Lakeview Parkway Reason for inspection: New instalation <br />Property owner: <br />Owner's phone: <br />or <br />Owner's representative: Brad Hayes Representative phone: 763-479-1762 <br />Local regulatory authority: City of Orono Regulatory authority phone: 952-249-4600 <br />Brief system description: Comments orrecommendations: <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: <br />Business name: <br />Inspector signature: <br />Roger Peitso <br />Necessary or Locally Required Attachments <br />® Soil boring logs ® System/As-built drawing <br />Certification number: <br />License number: <br />Phone number: <br />C6683 <br />952-249-4625 <br />Page 1 of 3 <br />