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Minnesota Pollution Compliance Inspection Form <br /> Control Agency <br /> 5201.afayette Raad North ��$ling Subsurface Sewage Treatment Systsms <br /> sc.Pa�,a,MN 55155-4194 (SSTS) <br /> Doc Type:Compliance and Enforcement <br /> Instructions: Inspection results based on Minnesota Pollution Con#rol Ag�ncy(MPCA) For local tracking purposes: <br /> requirements and attached forrns-additional local requirements may also apply. , <br /> Submit completed form to Local Unit of Gavernment(LUG)and system owne� ' <br /> within 15 days I_ ' <br /> System Status <br /> System status on date(mm/ddlyyyy): 6f02N7 <br /> � Compliant-Certificate of Compliance ❑ Noncompliant- Notice of Noncompliance <br /> (Valid for 3 years from report date, unless shoRer time (Ses Upgrade Requirements on page 3) <br /> frame outlined in Loca!Ordinance.) <br /> Reason(s)for noncompliance(check all appt�cable) <br /> ❑ Impact on Public Health(Compliance Component #f)-lmminent fhreat to public health and safety <br /> ❑Other Compliance Gonditions(Compliance Component#3)-Imminent threat to public hea/fh and safety <br /> ❑Tank Integrity(Compliance Camponent #2)-Failing fo protect groundwater <br /> ❑ Other Compliance Conditions(Comptiance Component#3)-Failing to protecf groundwater <br /> ❑Soil Separation (Compliance Component #4)-Failing to protect groundwater <br /> ❑Operating permit/monitoring plan requirements(Gomptiance Component #5)-Noncompliant <br /> Property Informatian Parcel ID#or Sec(fwp/Range: 3111823110Q12 <br /> ------ <br /> Property address: 560 Kokesh Farm Road Orono MN Reason for inspedion: Property Transfer <br /> __.__ <br /> Property owner: Brian Siska Owner's phone: 952-327-9391 <br /> or — _�.._� <br /> Owner's representative: __ _ _ Representative phone: <br /> ____ _. . <br /> _. __.._. <br /> Local regulatory authority: �,of Orono Regulatory authority phone: 952-249-4600 <br /> Approximately 2-1500 gallo�septic tanks,l-15Q0 gallon lift station and 750 square feet of mound rock <br /> Brief system description: bed rockbed. <br /> ___ _. _ _...._..-- ___ _._ -- <br /> Comments or recommendations: <br /> TBM:Top of lift station manhole cover <br /> Certification <br /> I heieby certify thaf al!the necessary information has been gathered to determine the compJiance status of this system. No <br /> determination of future system performance has been nor can be made due to unknown conditions during system construction, <br /> passible abuse of fhe system,inadequate maintenance, or fufure water usage. <br /> Inspector name: Joseph J Olson Certification number: 1255 <br /> _ _ ___ . . ._. . <br /> Business name: RustLr • ' 'I 8 Perc Testing License number. 810 <br /> Inspector signature`��,r� _ _ Phone number: 763-498-8779 _ <br /> Necessary or Locatly Required Attachments <br /> �Soil boring logs �SystemlAs-built drawing ❑Forms per local ordinance <br /> ❑ Other information{list): _ <br /> ._._.. � __ _ ___ _ -- <br /> www.pca.state.mn.us • b51-295-6300 • 800-557-3864 • TTY 651-282-5332 or 8�•657-3$64 • Avaitable in altemative formats <br /> wq-wwists4-31 • 1/T4/12 Page 1 of 3 <br />