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` Minnesota Rollution Complianc� Inspection Form <br /> Controt Agency <br /> 520 Lafayette Road Na�th Ex�sting Subsurface Sewage Treatment Systems <br /> St.Paul,MN 55t55-4194 ($�T$� <br /> Doc Type:Compliance and Entorcement <br /> Instructions: Inspection results based on Minnesota R�Ilution Control Agency(RAPCA) ; For local tracking purposes: '� � � <br /> requirements and attached forms—additionai local requirerraents may a#so apply. ' <br /> Submit compieted form ta Local Unit of Government(LUGj and system owner � <br /> within 15 days � <br /> System Status <br /> Systsm status on date(mrniddtyyyy): 514i2017 <br /> ',� Cornpliant--Certifi�ate of Compliance � Noncompliant- Notice of Noncompliance <br /> (Vatid for 3 years from report date, untess shorter time (See Upgrade Requirements on page 3) <br /> frame outlined in l.oca!Ordinance.) <br /> Reason(sy for noncompliance (check all applicab/e} <br /> ❑ Impact an Pubfic Health (Compliance Component #7)-lmminent threat ta pubJic health and safety <br /> ❑Other Compliance Conditions(Compliance Component#3)-Immrrrent thieat ta public health and safety <br /> ❑Tank lntegrity(Compliance Component #2)-Failing to pratect groundwater <br /> ❑Other CompUance Canditions(Complianc�Component#3)-Failing to protect groundwater <br /> ❑Soil Separatian(Complianc�Componen� #4}-Failing to pro#ect g►z�undwater <br /> ❑Operating permiVmonitoring plan requirements(Compliance Component #S}-Noncompliant <br /> P�roperty lnformation Parce!ID#or SeclfwplRange: 3119823110011 <br /> _ ..�_. ____ <br /> Property address: 575_Kokesh Farm Raad,Orono,MN _ Reason far inspection: Pro�e Transfer <br /> .___� <br /> Property owner: James„Leslie _ _ _� Owner's phone: 952-994-3839 <br /> or - -_ � �.__.— <br /> Owner's representative: _ __ ___ Representative phone: � <br /> __- _.. — <br /> Locai regulatory authoriry: _ City of Orono Regulatory authority phone: 952-249-4600 <br /> Approximately 1-1500, 1-1040 gallon septic tanks,1-1000 gaUon lift station and 630 square feet of � <br /> Brief system description: mound roekbed. <br /> _...... _.._. _. .___ .__- —�_........ _-- <br /> Comments or recommendations <br /> TBM: Top of lift station manhole cover <br /> Certification <br /> t hereby certify fhat al!the neces5ary infarrnaltion has besn gathered fo deferrnine fhe compliance sfafus of this system. No <br /> determinatron of future system performance has been nor can be made due to unknown conditions during system construction, <br /> possible abuse of the sysiem,rnadequate maintenance, or fufure water usage. <br /> ►nspectar name: Joseph J Olson Certification number: 1255 <br /> _.-_._._--___. ---_.... _ <br /> Business name: Rus�0 's Soil&Perc.Testing License number. 810 <br /> _ —_.._ __.—___ _ - <br /> inspector signature: '__ __ �-_ Phone number. 763-498-8778 <br /> Necessary r ocalty Required Attachments <br /> �5oil boring logs ❑ 5ystem/As-buiit drawing ❑Forms per local ordinance <br /> ❑ Other information{list}: <br /> _ _. ___.__---. — <br /> www.pca.siate.mn.vs • 651•296-6300 • 80Q-657-3864 • TfY 651-282-5332 or 8�-657-3864 • Avaitable in alterna[ive formats <br /> wa-wwists4-3f . J124l1� „ . �_ <br />