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.�,L Minnesota Pollution Compliance Ins ec�i:ion Form <br /> ,�.;, - <br /> Controi Agency p <br /> 520 Lafayette Road North �0�� ���e �age Treatment �ystems (SSTS) <br /> St.Paui,MN 55155-4194 Doc Type:Cor��pliance and Enforcement <br /> Inspection reSuitS based on Minnesota Pollution Control Agency(MPCA) I For�racking pu�poses: � <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/dd/YYYY1: 7/25/2017 <br /> � Compliant— Certificate of Compliance ❑ Noncompliant— Notice of Noncompliance <br /> (Valid for 3 years from report date, unless shorter time (See Upgrade Requi�ments on peg�; 3.) <br /> frame outlined in Loca/Ordinance.) <br /> Reason(s)for noncompllance (check all applicab/e) <br /> ❑ Impact on Public Health (Compliance Component#1)-Imminent threat to public health and safe�y <br /> ❑Other Compliance Conditions(Compliance Componenf#3)-Imminent threat to public health anc�safety <br /> ❑Tank Integrity(Compliance Component#2)-Failing to prvfect grr�undwater <br /> ❑ Other Compliance Conditions(Compliance Component#3)-Failing to protect groundwater <br /> ❑ Soil Separation(Compliance Component#4)-Failing to prntect groundwater <br /> ❑Operating permit/monitoring plan requirements(Compliance Component#5)-Noncompliant <br /> Property Information Parcel ID#or SeGTwp/Range: _ <br /> Property address: 145 S. Brown Rd. Orono _ Reason for inspection: Transf��r <br /> Property owner: John Winton Owner's phone: 612-708-012t: <br /> or --- <br /> Owner's representative: Representative phone: <br /> Local regulatory authority: Hennepin County Regulatory authority phone: <br /> Brief system description: Septic, secondary,pump chamber,gravity trenches <br /> Comments or recommendations: <br /> � <br /> Certification <br /> 1 hereby cert'rfy that all fhe necessary informadon has been gathered to dete►mine the compliance status of thi;�system. No <br /> determination of future system pe�formance has been nor can be made due to unknown conditions during sys�am construction, <br /> possible abuse of the system, inadequate maintenance, or fufune water usage. <br /> Inspector name: Matt Mckinle�_ _ _ _ Certification number: 8067 <br /> Business name: Mike's Septic+Mckinle Sewer Services _ _ License number: 2899 <br /> Inspector signature: Phone number: 952-440-�S00 <br /> Necessary or Locatly Re uired ttachments <br /> � Soil boring logs � SystemlAs-built drawing � Forms per local ordinance <br /> ❑ Other information(list): <br /> - _ ___ <br /> — _ _ .__ --- _ _ <br /> www.pca.state.mn.us • 651-2%-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in altemative formats <br /> wq-wwists4-31b • 6/4/14 Poge 1 of 3 <br />