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R 104/15/2010 11: 58 7634988290 RUSTYS PERC TESTING PAGE 09 Minnesota Pollution Compliance Inspection Form Control Agency Existing Subsurfaces Sewage Treatment Systems (SSTs) 520 Lafayette Road North St.Paul,MN 55155-4194 Instructions on page 7 Parcel number: 0411723220032 _ For Local Tracking Purposes: System status: ®Compliant ❑ Noncompliant (based on all compliance requirements) Summary Form Property Information Property owner name(s): Baker Homes Inc. Property address: 3085 Watertown Road. , Orono MN 55359 Property owner's address(it different): County: Hennepin Property owner phone: 651-276-0413 Permitting authority: Ci of Orono Date system constructed: 5129/82 _ Reason for Inspection: Property Transfer System Description Approximately 2-1000 gallon septic tanks, 1-1000 gallon lift station and Approximately 380 square feet of mound rockbed_The manhole cover on the first tank needs to be raised to 12 Inches below Brief system description: rade. - Local permit number: Number of bedrooms: 5 Design flow rate: _83 Is the system: In Shoreland area? ❑Yes ® No In Wellhead Protection Area? 0 Yes ® No An U.S. Environmental Protection System serving a Minnesota Department Agency(EPA)Class V Injection Well?❑Yes 0 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): 4/122013 ❑ Notice of Noncompliance-For Noncompliant systems: The reason for noncompliance is: This noncompllant system Is classified as(Check one below): ❑ Imminent threat to public health&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 certify that all the necessary informedon 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: Rus Olson's soil and perculation testing Lic#810 or Name of local unit of government: City of Orono _ Signature: Date: 4/14/10 Required Attachments Inspector Complete:Thls Inspection Report Is�_paltges Tong. 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 whet 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 meat to public health and satsty(ITPHS)must be upgraded,replaced,or its use discontinued within ten monms of recelpt of this nolke or wf Vn a shorter period H required by local ordinance,If the system is railing to protect ground water,ms system must be upgraded,rap*ced,or its uss discontinued within the time required by local Whence.d an existing system is nor fefNng as defined In law,and has at least two feet of design soil seperadon,then the system need not be upgraded,repaired,mpieced,or Its use dlsoonbnued,notwlMStanding any local ordinance mat Is more evict. This provision does not apply to Systems In shoraland areas,Welihsad Protection Am&$,or Mose used In connection with(food, beverage,and lodging estebtts/rments as defined In law. wq-wwists4-31 Compliance Inspection Form for Existing SSTS 414108