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, <br /> , ►v�innesota Pollution Compliance Inspection Form � <br /> Control Agency <br /> 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems <br /> St.Pdul,MN 55155-4194 �SSTs� <br /> Doc Type:Compliance and Enfortaemenf <br /> Instructlons: Inspection resuits based on Minnesota Pollution Control Agency(MPCA) For local tracking purposes: <br /> requirements and attached forms—additional local requirements may aiso apply. <br /> Submit completed form to Local Unit of Government{LUG)a�d system owner <br /> within 15 days <br /> System Status <br /> System status on date(mmldd/yyyy): 4/76/2093 <br /> � Compliant-Certiflcate of Compiiance ❑ Noncompliant- Notice of Noncompliance <br /> (Valid for 3 years frr�m�oport date, unless sho�fer t/me (See Upgrade Requir+aments on page 3) <br /> frame outlined in Loca/Ort�inance.) <br /> Reason(s)for noncompliance(check all applfcab/e) <br /> ❑Impact on Public Heallh(Compliance Component #1)—lmminent thr+�af to public health and safety <br /> ❑Other Compliance Conditions(Compliance Component#3)—lmminent fhreat to public health and safety <br /> ❑Tank Integrity(Compliance Component #2)—Failing to protect groundwater <br /> ❑Other Compllance Conditions(Compliance Componenf#3)—Failing to protecf groundwater <br /> ❑Soil Separation(Compliance Component #4)—Failing fo protecf groundwater <br /> ❑Operating permit/monitoring plan requirements(Compliance Componsnt fR5)—Noncompliant <br /> Property Information Parcel ID#or Sec/Twp/Range: 30111823330007 <br /> Property address: 4785 Creekwood Trail,Orono MN Reason for inspection: Proparty Transfer i <br /> Property owner: Lonnie&Marsha Underhill Owner's phone: 952-449-0068 G/�•`�o`I • S�v��' � <br /> or <br /> Owner's representative: Representaiive phone: , <br /> Local regulatory authority: City of Orono Regulatory authority phone: 952-249-4600 <br /> 11300and1000 gallon septic tanks,l-1300 gallon I(fl station and 68U square feet of mound rockbed.per <br /> Brief system description: city records I <br /> Comments or recommendations: P <br /> � <br /> I <br /> Certification <br /> � <br /> !hereby certify that aIl the necessary information has been gatherad to deteimine the compliance status of this sysfem.No <br /> detemrination of futu�a system perfoimance has been nor can be mads due to unknown conditions during system construction, <br /> possib/e abuse of the system,inadequate marntenance,or futur�water usage. I' <br /> Inspector name: Joseph J Olson CertificaUon number: 1255 <br /> Business name: Rusiy ql�son's Soil&Perc.Testing License number: 810 ' <br /> Inspector signatur�,r...t�----"''�i Phone number: 763-498-8779 <br /> . <br /> Necessary or Locally Required Attachments � <br /> �Soil boring logs �System/As-built drawing ❑Forms per local ordinance � <br /> ❑Other information(tist): � <br /> www.pca.state.mn.us • 651•296-6300 • 800•657-3864 . TTY 651-282-5332 or 800-657-3864 • Avaitable in alternative formats <br /> wq•mvlsts4•3i • 1/24/11 Page 1 of 3 <br />