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Mailing Address <br />P.O. Box 66 <br />Crystal Bay, MN 55323 <br />Street Address Certificate of Compliance <br />2750 Kelly Parkway <br />Orono, MN 55356 Inspection Form <br />Phone: 952-249-4600 Fax: 952-249-4616 <br />Website: www.ci.orono.mn.us <br />New Subsurface Sewage <br />Treatment Systems (SSTS) <br />Inspection results based on Minnesota Pollution Control Agency (MPCA) requirements and <br />attached forms System status on date 06/15/2020 <br />XD Compliant — Certificate of Compliance ❑ Noncompliant — Notice of Noncompliance <br />Valid for 5 years from report date (See Upgrade Requirements on page 3.) <br />Reason(s) for noncompliance (check all applicable) <br />❑ Impact on Public Health (Compliance 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) — Failing to 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 <br />Property address: 4154 Deborah Drive <br />Property owner: <br />or <br />Owner's representative: <br />Local regulatory authority <br />Brief system description: <br />Certification <br />Parcel ID# or Sec/Twp/Range: <br />Reason for inspection: New instalation <br />Owner's phone: <br />Kevin Barthel Representative phone: 612-919-0112 <br />City of Orono Regulatory authority phone: 952-249-4600 <br />Comments orrecommendations: <br />I hereby certify that all the necessary information 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: <br />Roger Peitso <br />Business name: <br />Inspector signature: <br />Necessary or Locally Required Attachments <br />® Soil boring logs ® System/As-built drawing <br />❑ Other information (list): <br />Certification number: C6683 <br />License number: <br />Phone number: 952-249-4625 <br />Page 1 of 3 <br />