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11/29/2011 18:57 7634988290 A RUSTYS PERC TESTING PAGE 02 C*OWW Minnesota Pollution Compliance Inspection Form Control Agency $20 Lafayette Road Nonh � �� a Treatment Systems (SSTs) St.Paul,MN 55155-4194 Instructions on page 7 Parcel number. 3311823440040 For local Tracking Purposes: System status: ®Compliant ❑ Noncompliant (based on ab compliance requirements) Summary Form Property Information Property owner name(s): Tim Corrigan Properly address: 155 Truffels Trail,Orono,MN 55356 w Property owners address(If dd owd): County: Hennepin Property owner phone: 962.475.0881 Permitting authority: _ V of Orono Date system constructed: -2113W Reason for inspectlon: .-Properly Transfer System Description Approximately 2-1000 gallon septic tanks,1-1000 gallon UR station and Approximately 500 square Brief system description: feet of mound rodtbed. Local permit number: Number of bedrooms: 4 Design flow rate: -.83 Is the sysbem: 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?❑You ® No of Heath(MDH)licensed facility? ❑Yes ®No Compliance Status(Based on state requirements-additional local requirements may also apply.) Based on the informadomgathered end reported on attached forms,the compliance status of this system is(check one): ®Certificate of Compliance-valid until(3 years Loan date of report): 11rAM14 ❑Notice of Noncompliance-For Noncompliant systems: The reason for noncompliance is: This noncompliant system Is classified as check one below): ❑lmminertt threat to public health S safety Failing to protect groundwater ❑Not in compliance with operating permit Certification(Completed form must be submitted to the local unit of govemment within 15 days.) I hereby cw ft that all the neoessary kft m mon has beorr gedhetsd to deft wir n6 the c�ompme ace status of Mia system.No determination ofhrture system psd mane has been not can be made due to iml mm conditions during sysism construction, possible abuse of thesystem,km dle4uate makftrance,ortutur® usage. _ _ . ... Name: Joseph J.Olson Certification number. 1255 Business license name and number. , ..Rusti Olson%soil and p2Tylation besting Lic IMS 810 or Name of I7uoMmmenl: City of OronoSignatureDate: 11/298011 Required Attach melpts Inspector Complete;This Inspection Report is.¢pages long. Check compliance OxMs atlachsd: I@ Hydraulic Pedbr mane' ®Tank Uibgrily ®Sod Sspwretion ❑Operating Pem*Form(if a �.Sykdem d As.bt*d ( ) a O r I rent ftom what Is required on this loan Sal Boring Absndor�maid form if (�.: rawrrp An as�insrrt d a local uiremsrrts-tlxffi ars dilfe pfjrsde Requrenwres(derived flan Atm.Stet§f 18.55)An U knmlrtatf iKietatta Pubic IterYlM bid SateN(ITPris)neat be uppradK r pWW,or Ns use dfsca ftW Wftn ter+mw4ft arrec W orae rratbe or ,a WWWW OM preaaked by local ordnance.NOra eysAem is Who to paled pMund mer M#srsrwn mua(De dpgrsded,rspac,ad,a its use discWtdh W wfrMn rhe Ow mWdrsd by Inca)ordinacen ./ran eXkft sydsm Is not rasing as do~to law,OW has at feast two feat of d6sipr wN sepem on,Men rho system need nat be upgraded,repbkiW MAWW,'a Ne use decw ttust not*W standMp any tical w*wmo that its mors strkt Tft WWSIW1 doer not appy to ayabms M shon►and areas VIMOW fs►orockm Arses,or those used M connacflan with tbod, bowso and W Mp arttaDNshorw to ass-deNaed in law.. wn.wwrctca.al rmmnlinnem rnenori-inn Ann"me Fvierino vq TC