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: Min�esota Pollution Compliance inspection Form <br /> � <�°-s����� Controi Agency <br /> 520 L,afayette Road Nonh Existing Subsurface Sewage Treatment Systems <br /> sc.P�,i,MN 55155-4194 (SSTS) <br /> Doc Type:Compliance and Enfoicement <br /> Instructions: Inspedion results based on Minnesota Pollution Controi Agency{MPCA) For local tracking purposes: <br /> requirements and attached forms-additional local requirements may also appfy. <br /> Submit completed form to Locai Unit of Government(LUG)and system owner <br /> within 15 days .......--- ' <br /> System Status <br /> System status on date(mm/dd/yyyy): 6i02/17 <br /> � Compliant—Certificate of Compliance ❑ Noncompliant— Notice of Noncompliance <br /> (Valid for 3 years from report date, unless shorter fime (See Upgrade Requirements on page 3) <br /> frame ouflined in Local Ordrnance.) <br /> Reason(s)for noncompliance(check all applicabteJ <br /> ❑ impact on P�blic Health(Comptiance Component #'1)-Imminent threat to public heatth and safety <br /> ❑Other Compiiance Conditions(Comptiance Gomponent#3)-lmmrnent threat fo public health and safety <br /> ❑Tank Integrity(Gompliance Component #2)-Faiting to protect groundwater <br /> ❑Other Compiiance Gonditions(Compliance Component#3)-Faifing to protect grnundwafer <br /> ❑Soil Separation(Compliance Component #4)-Faiting to protect graundwater <br /> ❑Operating permiUmonitoring plan requirements(Gompfiance Camponent #5)-Noncomp(iant <br /> � <br /> Property information Parcel ID#or SeclTwp/Range: 3111823110012 <br /> __ _ _ -- <br /> Property address: 560 Kokesh Farm Road Orono MN Reason for inspection: Property Transfer <br /> - -_. __ <br /> Property owner. Brian Siska _ Owner's phone: 952 327-9391 <br /> _ ._�... _ _ .__. �_ ..__ <br /> or <br /> Owner's representative: � .. __ Representative phone: <br /> _ _.... <br /> Local regulatory authority: City of Orono � Regu{atory authority phone: 952-249-4600 <br /> Approximately 2-1500 gallon septic tanks,l-15(}0 gailon lift statiort and 750 square feet of mound rock <br /> Brief system description: bed rackbed. <br /> __ _...... _...... ___ _.__ _._ _ .. <br /> Comments or recommendations: <br /> TBM:Top of lift station manhole cover <br /> Certification <br /> !hereby certify that alI the necessary information has been gathered to determine the compliance status of this system. Na <br /> determination of/utur�system performance has been nor can bs made due to unknown conditions dunng system construction, <br /> possible abuse of fhe system,inadequate mainrenance, or future water usage. <br /> Inspector name: Joseph J Olson Ce�tification number: 1255 <br /> _... ____. _ . __ <br /> Business name: Rusty ' 'oil&Perc.Testing License number: 810 <br /> Inspector signature: __ Phone number: 763-498-8779 <br /> _. .._ __ .___— <br /> �` <br /> Necessary or Locally Required Attachments <br /> �Soil boring logs � System/As-built drawing ❑Forms per local ordinance <br /> ❑Other information(list): <br /> � _�.._ _ � _.. _� <br /> www.pca.state.mn.us • 651•296•6300 • 800-b57-3864 • TTY 651-282-5332 or 8�-65T•3864 • Avaitable in altemative formats <br /> wq•wwists4-31 • 1l24/11 Page 1 af 3 <br />