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r Minnesota Pollutio� Comptiance Inspection Form : _ Control Agency 520 Lafayette Road North Exis+�se�g Ss�bs� sfa��S� e Te�ea� . e�t.�!�ex�.{�..�7'�� .�-.�..�.� 5�Paul,MN 55155-4194 ��j {��jo11S 011 plge 7 Parcel number. 04117233t0015 "- ` or Local Tracking Purposes_ System status: �Compfiarrt ❑N�compliarrt ` �� (based on all�mpliance requirements // 1 � Summary Form �, � /� / Property Information � �' Property owner name(s}: Claudi W Property address: 2980 Sussex Road,Or�o,MN 55356 Property ovur�ers address(�f d�ferern): County: Hennepin Property owner phone: 612-860-8560 Permitting authority: __City of Orono Date system constructed: 5/08/04 Re.ason for inspec�iorr Pro�Transfer System Dexription Appro�dmaiely 2-1300 gallon septic tenks,1-1300 ga)lon pft�tion and Appro�6matefy 630 square Brief system description: fset af mamd rockbed. Locai pertnit number: Number of bedrooms: 5 Design flow rate: .83 ls the system: Irt Shoreland area? �Yes ❑No In We(Ihead Protection Area? Q Yes �No M U.S.Enviranr►�ental Protection System serving a Minnesota Department Agency(EPA)Class V Injedion We1t?0 Yes �No of Heath(MDH)licensed faaTity? ❑Yes �No Compliance Status{eased o�state requirements—acw;6ona��oca�reyu;rements may also appry_) Based on the information gathered and reported on attached forms,the oompliance status of this system is(chedc one): �Certificate of Compliance—valid until{3 years fr+�m date of report). 7)132014 ❑Notice of Noncompliance-For Nonc�mpiiar�t systems: The reason for noncompl'�ance is: This noncompliant system is dassified as(chedc one below): ❑imminerrt threat to pubtic health�safety ❑Failing to pratect ground water ❑Not in compfiance with operating pertnii CErt1f1Cdt1011(Completed form must be submitted to the Ioca1 unit of govemmertt wdhin 15 days.) l hereby ce�fily fhaf al/the necessary infomraba�has been gathe►ed to defemrine the comp�ance status of this system.No deterr»inatiat of future system performance has been nor can be made due to unknown conditions during system consbucbor►, possible a6u�of the sysfem,inadequate mair�tenance,or futuie water usage. Name: Joseph J.Olson Cer6ficafion number. 'l255 Business Gcense name and number. Rusty Olson's soil and perculation testinq Lic#810 or Name of local unit o ov C' of Orono Signature: __ Date: 7/15/11 Required Attachments i�s�or compie�e:Th�s�nspect�on Report is s pa9es iong. Check complianee#ortns atteched: �Hydraulic Perfortnance �Tank Integrity �Sal Separation ❑Operafing Permit Fortn(if applipble3 �System dtawing/As-buift drawing ❑An assessmerrt of arry loCal requiremer�ts that are d'�ffierent from what is rayuired on this fortn �Soil Boring Logs ❑Abandonrt�M torm(3F appropriate) ❑Uther infom�ation pist): UpgrBde Requifem@nts(deri�d from 11�rrfn.Stst.§115.55)M imminent Uxeet to pubGc hea�th and sa/ety pTPHS)must be upgraded,replaeed,or ils use dttc�6nued wi�in fen months of reaeipt offf��s notice or w�7hin a shorterperiod if required by local�irdnce_IitAe system Is faifmg io proted ground wale�the sysfem must be upgraded,replaced,ords use discon8nued wifhin the fime required by toca/ortlinance.lfan existirrg system is not fail'mg as defined!n law,and has at least 1wo feet otdesign sor7 separeSon,then lhe system need not 6e upgraded,repaired,rep/aced,or;ts use disca�tinned,notwiHrstanding any loca!ordinartce d�at is mo2 strid This proHsion does not appl�!'to systems in shoreland areas,Wellhead Proteefion Artas,or drose used in con�c0ip�wiM/ooal, beverage and/odging estabfrshments as defined in law. wq-wwists4-31 Com (iQnce 1 4l4108 P nspection Form for Existing SSTS