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Oct 20 14 10:59a Joseph Olson 763-498-8290 p.2 <br /> Minnesota Pollution Compliance Inspection Form <br /> Cantrol Agency <br /> 520 LafayettaRoad North Existing Subsurface Sewage Treatment Systems <br /> St Paul,MN 55155-419q �S$T$� <br /> Doc Type�Compliance and Enforcemenf <br /> Instructior:s: Inspection nesulls based on Minnesota Pollution Contro!Agency(MPCA) � For local traehing�py�g� �� <br /> requirements and attached forrns—additior�al local requiremen#s may afso apply. RG�.sCI Y G <br /> Subrnit completed form to Local Unit of Government{LUG)ancf system owner Q� �Q�0�4 <br /> within 15 days �_ <br /> System Status CITY Of ORgl�1�3 <br /> System status on date(mm/ddlyyyy): 810112014 <br /> � Compliant-Certificate of Compliance ❑ Noncompliant- Notice of Noncompliance <br /> (Valid far 3 years fiom report dafe, unless shortef 6me (See Upgrade Requirements on page 3) <br /> frame outlrned in Loca!Ordinance.) <br /> Reason{s)for noncompliance(check al1 applicableJ <br /> ❑ fmpact on Publ�c Health (Compliance Component #9)—lmmrnent fhrea£to publrc health and safefy <br /> ❑Other Compliance Conditions(Compliance Comporrent#3}—lrnminent threat to pub/ic healih and safety <br /> ❑ Tank Integrity(Comp/rance Component #2)—Failing to profect,qroundwater <br /> ❑ Other Compliance Condilions{Compliance Componenf�13)—Failing to profect groundwater <br /> ❑Soil Separation(CompliaRce Component #4)—Failing to protectgroundwater <br /> Ci Operating permiUmonitoring plan requirerr►ents (Compfiance Component #5J—Noncompliant <br /> Property Information Parcel ID#or Sec/Twp/F2ange: 34-11$-23-22-OD06 <br /> Property address: 725 Dicke�+Lake Road,Orono, MN Reason for inspection; Property Transfer <br /> Prope�ty owner: Patnck Pu�h _ _ Owner's phone: <br /> or i -- <br /> Owners representative: .Eohn Adams __ Represenlative phone: 612-269-9438 <br /> —.._ _ <br /> Local regulatory authority: _Ci of prono _ Regulatory authority phone: 952-249-460Q <br /> 2-1000 gallon septic tan�cs,1-1000 gaElon iift station and 500 square feet of rnound rockbed.per city <br /> Brief system description: records <br /> — _ -- - — -----__ _ <br /> Comments or recomrnendaGons: <br /> Certification <br /> I hereby cerfiry that aU the necessary information has been gathered fo detenrrine the compliance status of this system.IVo <br /> defermination of future systern perfomrance has been�orcan be made due fo unknown conditions during system consfnrction, <br /> possi6le abuse of the sysfem, inadequate maintenance, or k�ture wafer usage. <br /> Inspector name; Joseph J Olson Cerlification number. 1255 <br /> Business name: _Rusi�Olsan's Soil&Perc.Testin� License number: 816 <br /> Inspector signature: _____ Phone numher: 763-498-8779 <br /> Necessary or Locally Required Attachments <br /> ',� Soil boring logs �SystemlAs-built drawing ❑ Forms per local ordinance <br /> ❑ Other in(ormation(list): <br /> www.pcastate.mn.us • 651-296-6300 • 800-657-3864 • TTY G51•282-5332 or 800-657-3864 • Availabte in a(temative fortnats <br /> wq-mvists4-3t • 1/14112 Page 1 of 3 <br />