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Mar 11 13 01:25p Joseph Olson � 763-498-8290 p.2 <br /> . �c" � <br /> . ��,r �� . . <br /> Minn sota Pollut�on � �� �ompliance Inspect�on Form <br /> Contr ] Agency � <br /> 520 Laf ette Road►dorth � Ex�sting Subs�rface Sewage T�eatrr�ent Systems <br /> Sc.Paul, �v ss�ss-ai�a � (SSTS) <br /> Doc Type:Compfiance and Enforcement <br /> Instructions: tnsp ction results based on Minnesota Pol�ution Control Agency(MPCA) For local tracking purpos�s: <br /> requirements and a ached forms—additiortal local requirements rnay also apply. <br /> Submit complete form to Local Unit of Government(LUG)and system owner <br /> within 15 days <br /> Systern Statu <br /> SystEm sta s on date(mm/dd/yyyy): 3106/'E3 <br /> � Compli nt— Certificate of Compliance ❑ Noncomplrant— Notice of Noncompliance <br /> {Va/id fo 3 years frofri roport date, unless sf�orter bine (See Upgrade Requrr�ments on page 3) <br /> frame ou ined in�ocal Ordinance.) <br /> Reason(sy pr noncompliance (check al!applicableJ <br /> ❑ Impact�On Public Health (Compliance Component #1)—lmminenf threat to public healfh and safety <br /> f ❑ Other�om pliance Conditions(Complrance Componenf#.3)—lmrr�inent fh�at to public health and safiety <br /> 1 <br /> ❑Tank Ir�tegrity(Compliance Component #2)—Failing fo protect graundwater <br /> ❑ Other Qompliance Conditions(Compliance Component#3J—Faifing to prot�c[groundwater <br /> ❑ Soil Se�paration (Compliance Component #4)—Failing to protecf groundwater <br /> ❑ Operai�ng permit/moniloring pfan requirements(Comp6ance Component #5)—Noncompliant <br /> Property Info ma�j011 Parcel ID#or Seclfwp/Range: 331182340022 <br /> Property address: . 160 Golden View Dr., Ororto, NIN Reason for inspection: Properly Transfer <br /> Praperty owner. �Curt 8�Carol Schmid Owner's phone: 952-449-0847 <br /> or <br /> Owner's represent�tive: Representative phone_ <br /> Local regulatnry au hority: City of Orono Regulatory authority phone: 952-249-460o <br /> � 2-1000 gallon sepiic tanks,l-1000 galfon li�t stafion and 630 square feet of rnound rockbed.per city <br /> Brief systerrr descn�tion- records <br /> CommeMs or reco mendations: <br /> Certification <br /> I hereby cerfify tha#al/the necessary information has been gathered to defemtine the camplianee status of this system. No <br /> deferminafior�offut re system performance has been norcan be made due to unknvwn co�rditions duRng system construcSon, <br /> possible abuse of t e system,inadequate maintenance,or future water usage. <br /> Inspector name: ose h J Olson Cert�cation number: 125� <br /> Business name: ust Ofson's Soil 8� Perc.Testin License number 810 <br /> Inspector signaturet Phone number: 763-498-8779 <br /> ,; <br /> Necessary or �ocally Required Attachments <br /> �Soil boring log�s �SystemlAs-built drawing ❑ Forms per loca)ordinance <br /> ❑Other informa�on (list): <br /> I <br /> www.pta.staLe.mn. • 651•29h-6300 • 840-657•3864 • TTY 651-282•5332 or 800-657-3864 • Available in altemative formats <br />