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02/26/2016 10: 14AM FAX 9528733112 �0001/0003 <br /> � ���:��,,,� MinnesotaPollution Compliance Inspe�tion Form <br /> ���,�,�,� Cantrol Agency <br /> 520 Lafayette Road North �xisting SubsurFace Sewage Treatment Sysfiem� (SSTS) <br /> St.Paul,MN 55155-4194 Doc Type:Complisrtce end Enforcement <br /> InspeCtion reSults based on Minnesata Pollution Control qgency(MPCA) For local trac���ED � <br /> requirements and attached forms—additfanal looal requirements may also apply. <br /> Submit completed form to L.oca! Unif ofi Government(LUG)and system owner FEB 2 6�Q�� I <br /> within 15 days __ <br /> �TM��RONO <br /> System Status <br /> System status on date(mmldd/yyyy): 2/24/2016 <br /> ❑ Gampliant—C�rtificate of Compliance � Nvncompliant— Notice of Noncompliance <br /> (Valid for 3 years from report date, �nl�ss shorter time (See Upgrade Requirements on page 3.) <br /> freme ouflined in Local Ord;nance.) <br /> Reason(s)for noncompliance (check all applicgble) <br /> ❑ Impact on Public Health(Compliance Componenf#1)—lmminent threat to pu611c health�nd safefy <br /> ❑ Other Complfance Canditions(Compliance Component#3)—Imminent threat to public health and safety <br /> ❑ Tank Integrity(Compliance Component#2)—�ailing to profect groundwater <br /> ❑ Other Compliance Conditions(Compliance Component#3)—Failrng fo protect groundwater <br /> � Soil 5eparation(Compliance Componenf#4)—Failing to protect groundwater <br /> ❑ Operating permiUmonitoring pfan requirements(Comp(iance Gomponent#5)—Noncomplianf <br /> Pro�erty Informatio� Parce! ID#or SeclTwp/Range: <br /> Property address: 2465 French Laka Road,Orono, MN Reason for inspection, Sale <br /> Property owner� Joan Dayton Owner's phone: 852-475-9207 <br /> or --- <br /> Ownsr's representative: Representative phone: <br /> Local regulatory authority: Regulatary authority phone: <br /> Brief system descriptiorc: _ <br /> Comm�nts or recommendations: � <br /> Certification <br /> J hereby certify fhat a!I the necessary information has be�n gathered to determrne the c�ompliance sfatus of fhis system. No <br /> determination of future syst�m peri'ormance has been nor can be mede due to unknown conditions during system constructfon, <br /> possib/e abuse of the system,inadequste maintanance, or fufure water usage. <br /> Inspector name: Josh Swedlund Certification number: C1659 <br /> Business name: Swedlund Septic Service Licanse number 2502 <br /> Inspectorsignature;�� 7,�,�,�,� ��d _ 1 _ _ Phone number. 952-873-3292 <br /> Necessary or Locally Required Attachments <br /> � Soil boring logs ❑ System/As-bui[t drawfng ❑ �orms per local ordlnance <br /> ❑ Other information(list)� <br /> www.pca.state.mn.us • 651•296-63QQ • 800-657-3864 • TTY 651-282-5332 or 800-557-3864 • Availablc in alternative formats <br /> wq•wwists4-31 . 3/16112 Page f of 3 <br />