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` Minnesota Pollution Compliance Inspection Form <br /> Control Agency <br /> 520 Lafayette Road No�h Existing Subsurface Sewage Treat�nent Systems <br /> St.Paul,MN 55755-4194 �s$TS� <br /> Doc Type:Compliance and Enforcement <br /> — —___.._.._. --.—_—,. <br /> Instructions: Inspection results based on Minnesota Poliution Control Agency(MPCA) : For lacai tracking purposes: j <br /> requirements and attached forms—additionai loca!requirements may aiso appiy. � <br /> Submit compieted gorm to Local Unit of Govemment(LUG)and system awner � <br /> within 15 days - ,�� <br /> �` ._ <br /> ------.._._ <br /> _.____.. <br /> System Status <br /> System status on date(mmldd/yyyy): 5/4/2017 <br /> � Compliant--Certiflcate of Compliance ❑ Noncompliant— Notice of Noncompliance <br /> (Va/id for 3 years from report date, unless shorter time (See Upgrade Requirements on page 3) <br /> frame outlined in Lcxal Ordinance.) <br /> Reason(s'for noncampliance (check al!applicabte) <br /> ❑ Impact an Public Health(Campliance Compo€rent #1)—Imminent threat to public health and safety <br /> ❑Other Compliance Conditions(Cor�npliance Componer►f#3}—lmminent threat to publrc health and safety <br /> ❑Tank Integrity(Complr'ance Component #2)—Failing fo protect grc�undwater <br /> ❑Other Compliance Conditions(Compliance Componeni#3)—FaiJing to profect groundwater <br /> ❑Soil Separation(Compliance Component #4)—Failing to protect groundwater <br /> ❑Operating permiUmonitoring plan requiremenis(Compliance Component #5)—Noncomplianf <br /> Property information Parcel ID#or Secffwp/Range: 311182311,0�17 <br /> -- <br /> r roperty address: 575 Kokesh Farm Road,Orono, MIV __ Fteason for inspection: Prope Transfer <br /> ___ <br /> Property owner: James Leslie Owner's hane: 952 994-3839 <br /> —_.. �... — —�_._ P — _ _ ___ __.___..._.� <br /> or <br /> Owner's representative: Representative phone: _ <br /> Local regulatory authority: _ City of Orono Regulatory authority phone: 952-249-4600 ' � <br /> -- �._—.____.___._ <br /> Approximately 1-1500, 1-1040 gallon septic tanks,1-1000 gallon lift station and 630 square feet of <br /> Brief system description: mound rockbed. <br /> _ �.. _�, ..._._ _�_.__.— <br /> Comments or recorrtmendations: <br /> TBM: Top of fift station manhole cover <br /> CertifiCattOn <br /> 1 irereby certrfy that al(the necessary information has been gathe�d fo determine the campliance status of this system. No <br /> determination of future systern performance has been nor can be made due to unknown conditions durrng system construction, <br /> possible abuse of the system, rnadequate marntenance, or futur�s water usage. <br /> Inspeetar name, Joseph J Olson Certification number: 1255 <br /> _ _._._.__ <br /> Business name: Rusty_O s Soii& Perc.Testing License number: 81Q <br /> __ _ _—.__.__.e=.. ._..� <br /> Inspectar signature: __ __ __ Phone number: 763^498-8779 <br /> Necessary r ocally Required Attachments <br /> � Soil boring logs []Systerts/As-bui(t drawing ❑ Farms per local ordinance <br /> ❑ Other information(Eist): <br /> __ __. _____.__.-----____ ._ <br /> www.pca.state.mn.eas • 651-296-63� • 800-657-3864 • TTY G51-282-5332 or 800-657-3864 • Availabte in altetnative forrnats <br /> wo-wwists4-3 r . t/24/i? R . ... <br />