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i Minnesota Pollution Compliance Inspection Form vd Control Agency 520 Lafayette Road worth Existing Subsurface Sewage Treatment Systems (SETS) St.Paul,MN 55155-4194 Instructions on page 7 i Parcel number: 0411723110022 For Local Tracking Purposes: System status: ®Compliant ❑ Noncompliant (based on all compliance requirements) Summary Form Property Information Property owner name(s): Stephen&Katherine Poley Property address: 2605 Thoroughbred Lane,Orono, MN 55356 Property owner's address(if different): County: Hennepin Property owner phone: 952-4041413 Permitting authority: City of Orono Date system constructed: 5/5/98 Reason for inspection: Property Transfer System Description Approximately 2-1300 gallon septic tanks, 1-1300 gallon lift station and Approximately 750 square Brief system description: feet of mound rockbed as per city records. Local permit number: Number of bedrooms: 6 Design flow rate: .83 Is the system: In Shoreland area? ®Yes ❑ No In Wellhead Protection Area? ❑Yes ®No An U.S.Environmental Protection System serving a Minnesota Department Agency(EPA)Class V Injection Well?❑Yes ® No of Heath(MDH)licensed facility? ❑Yes ® No Compliance Status(Based on state requirements—additional local requirements may also apply.) Based on the information gathered and reported on attached forms,the compliance status of this system is(check one): ®Certificate of Compliance—valid until(3 years from date of report): 10/9/2010 ❑ Notice of Noncompliance-For Noncompliant systems: The reason for noncompliance is: This noncompliant system is classified as(check one below): ❑ Imminent threat to public health&safety ❑ Failing to protect ground water ❑ Not in compliance with operating permit Certification(Completed form must be submitted to the local unit of government within 15 days.) i hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No determination of future system performance has been nor can be made due to unknown conditions during system construction, possible abuse of the system,inadequate maintenance, or future water usage. Name: Joseph J.Olson Certification number: 1255 Business license name and number: Rusty Olson's soil and perculation testing Lic#810 or Name of local unit of overnment: City of Orono Signature: Date: 10/09/10 Required Attachments Inspector Complete:This Inspection Report is pages long. Check compliance forms attached: ®Hydraulic Performance ®Tank Integrity ®Soil Separation ❑Operating Permit Form(if applicable) ❑System drawing/As-built drawing ❑An assessment of any local requirements that are different from what is required on this form ®Soil Boring Logs ❑Abandonment form(if appropriate) ❑Other information(list): Upgrade Requirements(derived from Minn.Stat.§115.55)An imminent threat to public health and safety(ITPHS)must be upgraded,replaced,or its use discontinued within ten months of receipt of this notice or within a shorter period if requited by local ordinance.!f the system is failing to protect ground water,the system must be upgraded,replaced,or its use discontinued within the time required by local ordinance.If an existing system is not failing as defined in law,and has at least two feet of design soil separation,then the system need not be upgraded,repaired,replaced,or its use discontinued,notwithstanding any local ordinance that is more strict This provision does not apply to systems in shoreland areas,Wellhead Protection Areas,or those used in connection with food, beverage,and lodging establishments as defined in law. wq-wwists4-31 Compliance Inspection Form for Existing SSTS 4/4/08 r _ _ _