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,,or, Minnesota P011iltion Control Agency Compliance Inspection Form 520 Lafayette Road Worth Existing Subsurface Sewage Treatment Systems St. Paul, MN 55755.4194 (SSTS) Doo Type: Compliance and Enforcement Instructions: Inspection results based an Minnesota Folluti3n Convol P,yency (11lPCA) For local tracking purposes: requirements and attached forms — additional local requirements may also apply, Submit completed form to Local Unit of Government (LUG) and system owner within 15 days System Status System status on date (mmlddlyyyy): 5/1212014 ® Compliant — Certificate of Compliance ❑ Noncompliant -- Notice of Noncompliance (Valid for 3 years from report date, unless shorter time (See Upgrade Requirements on page 3) frame eutlined in Local Ordinance.) Reason(s) for noncompliance (check all applicable) (] Impact on Public Health (Compliance Component #1) — Imminent threat to public health and safety ❑ Other Compliance Conditions (Compliance Component #3) — Imminent threat to public health and safety ❑ Tank Integrity (Compliance Component #2) — Failing to protect groundwater ❑ Other Compliance Conditions (Compliance Component #31— Failing to protect groundwater ❑ Soil Separation (Compliance Component #4) — Failing to protect groundwater ❑ Operating permittmonitoring plan requirements (Compliance Component #5) -- !Noncompliant Property Information Parcel IDA or Sec/TwplRange: 2711823320018 Piciperly address: 1000 Cox Farm Road, Long Lake. MN 553M Reagon for inspection: Transfer of Title Property owner: David Narum Owner's phone: i or _...- w Owner's representative: Representative phone: Local regulatory authority: City of Orono _ _ Regulatory authority phone: _ Brief system description: Pre --cast Septic Tanks, and above grade drainfeld Comments or recommendations - Tanks should be pumped on a regular basis to make sure solids do not enter the drainfeld from the pump tank Septic tank sizes were a(1) 1300 gallon septic tank, (1) 1000 gallon septic tank, and a (1) 1000 gallon pump tank. Certification I hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No determination of future system performance has been nor can be made due to unknown conditions during system construction, Possible abuse of the system, inadequate maintenance, Or Mum water usage. Inspector name: Pero ip s Certification number: _ Business name: Chip' optic Se v' � License nuniber. _2064 Inspector signafrlre _ Phone number, 952-200-3176 Necessary or Locally Required Attachments ® Soil boring logs ® SystemlAs-built drawing ❑ Other information (list): www.pca.state.mn.us 651-296-6300 800-657-3864 wq-wwists4.3I • 1124112 ❑ Forms per local ordinance • TTY 651-282-5332 or 800.657-3864 • Available in alternative formats page t of 3