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01/19/2007 23:06 7634988290 RUSTYS PERC TESTING PAGE 03 1/29/02 Water/Wastewater-IST94.31 Compliance inspection Form for Existing Individual Sewage Treatment Systems Minnesota Pollutlorr conbrlol Agency t:ornpietion of this form fuififls the n"mal requirements of Alnn.Stat§115.55(?001)and Minnesota R.ch. 70W(1999). Please refer to local ordinances for other ulrements or inflormallon for Nance ithm tints lrar bedroom addMons. i Date of inspection:01/19/07 REASON tlbr Irrslheaio R BVIMM TNUft P1 operty Owner(s)Ron Manson Telephone(9S2) 475-0288 , Person requesting Inspactlon: Telephone Sibs Add- n-- 1183 Whvndmarn Road- city: Orono Zip Code 553 1 Ire W Par+gsl No. county: Heinnedn Township: sepal Description Local Regulatory Autiarity:SU of 989 Date system aonsbvcted: 9/29/84 System In Shoreland Area: yes no System In Wellhead Protection Area: yes no System servltng a MDIs licensed fadllty: yes no Local Permit 8 (If any) 7624 Systems built prior to April 1, 2996 and not located In Systems located In Shoreland or Wellhead Protection Slwrleland W Wellhead Protection Area or Serving a Food, Meas or Serving a Food, Beverage or lodging Beverage or Lodging Establishment Establishment,or systems Built after Metxfi 31 1996 Is the MMMM an imminent threat to RUblic health Is the lgd=an lmmlDM threat to ggbllc health Idlita(a yes answer h an II P16 system) " Q ty?(a yes answer 1s an TMS system) -DL%Nrge of sewage to the ground surface? YES -Discharge of sewage to the ground surface? YES NO - Discharge of 9eMrdge to dralndle or surface wagers? YFS -Discharge of sewage to draintlle or surface waters?YES NO -Sewage backup Into dwelling? YES NO -Sewage backup into dwelling? YES NO -Situation with,the potential to Immediately and -Situation with the potential to Immediately and adversely Impact or threaten public health or adversely impact or threaten public health or Rd*? YES &'O safety? YES NO Is the system falling?(a M answer Is a failing,system) Is the system falling?(a yes answer Is a failing system) -Mess than TWO feet of vertical separation between -Less titan THREE feet of vertical separation between systern bottom and saturated soil or bedrock? YES system bottom and saturated soil or bedrock? YES NO A seepage pig,cesspool,drywell,or leaching pit? YES -A Seepage pit,cesspool,drywell,or leaching pit? YES NO Is the system non-oomnllantT Is the system non-comglJanV - Is the system regulated under a monitoring plan or � - Is the system regulated under a monitoring plan or operalinR permit? (if no, go to page 2) YES fNo/ operating permit? (if no, go to page 2) YES NO /fines, �� If yes, - Has the required monitoring taken place? YES NO -Has the required monitoring taken place? YES NO (if no, the system is non-complying) (If no, the system is non-complying) -The monitoring indicate that the system meets -The monitoring indicate that the system meets performance expectations? YES NO performance expectations? YES NO (K no. the system is non-complying) (If no, the system is non-complying) Page 1 of 2 wq-vvwists4.31