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i <br /> �4► Minnesota Pollution Compliance Inspection Form <br /> . Control Agency <br /> 520 Lafayette Road North Existing Subsurface Sewage Treatrnent Systems <br /> St.Paul,MN 55155-4194 ($ST$� <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 aiso 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/yyyy): 5/12/2014 <br /> � Compliant-Certificate of Compliance ❑ Noncompliant- Notice of Noncompliance <br /> (Valid for 3 years from report date, unless shorter time (See Upgrade Requiiements on page 3) <br /> frame ouflined in Local Ordinance.) <br /> Reason(s)for noncompliance (check all applicable) <br /> ❑ Impact on Public Health (Compliance Component #1)—lmminent threat to public health and safety <br /> ❑ Other Compliance Conditions(Compliance Component#3)—Imminent threat to pub/ic 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 groundwafer <br /> ❑ Operating permiUmonitoring plan requirements(Compliance Component #5)—Noncomp/iant <br /> Property Information Parcel ID#or Sec/Twp/Range: 2711823320018 <br /> Property address: 1000 Cox Farm Road, Lonq Lake, MN 55356 Reason for inspection: Transfer of Title <br /> Property owner: David Narum Owner's phone: <br /> or <br /> Owner's representative: Representative phone: <br /> Local regulatory authority: City of Orono Regulatory authority phone: <br /> Brief system description: Pre-cast Septic Tanks, and above qrade drainfield <br /> Comments or recommendations: � <br /> Tanks should be pumped on a regu(ar basis to make sure solids do not enter the drainfield from the pump tank Septic tank sizes <br /> were a(1) 1300 gallon septic tank, (1) 1000 gallon septic tank,and a(1) 1000 gallon pump tank. <br /> Certification <br /> I hereby certify that al!the necessary information has been gathered to detennine the compliance status of this sysfem. No <br /> determination of future system performance has been nor can be made due to unknown conditions during system construction, <br /> possib/e abuse of the system, inadequate maintenance, or future water usage. <br /> Inspector name: Pern i s Certification number: <br /> Business name: Chi ' e tic Serv' License number: 2064 <br /> Inspector signature: Phone number: 952-200-3176 <br /> Necessary or Locally Required Attachments <br /> � Soil boring logs � System/As-built drawing ❑ Forms per local ordinance <br /> ❑ 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 attemative formats <br /> WO'WW]Sf44-.3� • 1/74/17 � Dnnn 1 nF Z <br />