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Minnesota Pollution Compliance Inspection Form <br /> Control Agency <br /> 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems (SSTS) <br /> St.Paul,MN 55155-4194 Doc Type:Compliance and Enforcenjent <br /> Inspection results based on Minnesota Pollution Control Agency(MPCA) For local tracking purposes: <br /> requirements and attached forms--additional local requirements may also apply. <br /> Submit completed form to Local Unitlof Government(LUG)and system owner <br /> within 15 days <br /> System Status <br /> o <br /> System status on date(mmidd/yyyy): 2/19/2019 <br /> Compliant— Certificate of Compliance ❑ Noncompliant— Notice of Noncompliance <br /> (Valid for 3 years from report date, unless shorter time (See Upgrade Requirements on page 3.) <br /> frame outlined in Local Ordinance.) <br /> Reason(s)for noncompliance (check all applicable) <br /> ❑ Impact on Public Health (C4mpliance Component#1)–Imminent threat to public health and safety <br /> ❑ Other Compliance Conditions (Compliance Component#3)–Imminent threat to public health and safety <br /> ❑ Tank Integrity (Compliance Component#2)–Failing to protect groundwater <br /> ❑ Other Compliance Conditions(Compliance Component#3)–Failingto protect groundwater <br /> ❑ Soil Separation(Compliance Component#4)–Failing to protect groundwater <br /> ❑ Operating permit/monitoring plan requirements(Compliance Component#5)–Noncompliant <br /> Property Information Parcel ID#or SeclTwp/Range: <br /> Property address: 4745 Creekwood Trail,Orono _ Reason for inspection: _sale <br /> Property owner: Colleen Yockey Owner's phone: 612-581-0764 <br /> or <br /> Owner's representative: _— Representative phone: <br /> Local regulatory authority: City of Orono _ Regulatory authority phone: <br /> Brief system description: 1250& 1000 septic&1250 Gallon pump tank with a mound system <br /> Comments or recommendations: <br /> Certification <br /> I hereby certify that all the necessary infprmation has been gathered to determine the compliance 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 /> possible abuse of the system, inadequate maintenance, or future water usage. <br /> Inspector name: Josh SwedluCertification number: C1659 <br /> Business name: Sewer Sega In Air License number: 2502 <br /> Inspector signature: t7 / 4 •. Phone number: 952-873-3292 <br /> Necessary or Locally Required Attachments <br /> ® Soil boring logs E System/As-built drawing E Forms per local ordinance <br /> ❑ Other information (list): <br /> www.pca.state.mn.us • 651-296.6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats <br /> wq-wwists4-31 • 3/16/11 Page 1 of 3 <br />