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10129/2010 11: 29 7634988290 RUST'S PERC TESTING PAGE 02 Minnesota Pollution Compliance Inspection Form w Control Agency 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems (SETS) St.Paul,MN 55155-4194 Instructions on page 7 Parcel number: 26-118-23-41-0009 For Local Tracking Purposes: System status: ®Compliant ❑ Noncompliant (based on all compliance requirements) Summary Form Property Information Property owner name(s): _Richard Seitz Property address: 1185 Wyndmere Road Property owners address(if ditrant): County: Hennepin ` Property owner phone: 952-5.45-1005 Permitting authority: City of Orono Date system constructed: 9/25/84 Reason for Inspection: Point of sale System Description 1-approximately 15M gallon septic tank.,1-approximately 1000 gallon lift station and Approximately Brief system description: 1500 square feet of trench Local permit number: 7624 Number of bedrooms: 5 Design How rate: 1.0 Is the system: In Shoreland area? ❑Yes 0 No In Wellhead Protection Area? ❑Yes ® No An U.S. Environmental Protection System serving a Minnesota Department Agency(EPA) Class V Injedion Well?❑Yes ® No of Heath(MDH) licensed facility? E]Yes M 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): 10/18/2013 ❑ Notice of Noncompliance-For Noncompliant systems: The reason for noncompliance is. This noncompliant system is classified as(check one below): [I 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 neoessary 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 N� Certification number 1255 Business license name and number: Rusty Olson's soil and peroulatlon testing 810 or Name of local unit o government: Signature: _.. Date: 10/23/10`�N^` Required Attachments Inspector Complete, This Inspection Report is_L_pages long. Check compliance forms attached: ®Hydraulic Performance IR Tank Integrity ®Soil Separation ❑Operating Permit Form(if applicable) ®System drawing/Ats-bulli drawing (]An assessment of any local requirements that are different from what Is required on this form ®Soil Boring Logs ❑Abandonrrmrrt form(if appropriate) ❑Other information(list). Upgrade Requiremenfmts (derived}term/Minn,Stet.§115.55)An imminent threat to pubfic health and safety(17PHS)most be upgraded,replaced,or cls use d/seonbnued within fen months of receipt or this notice or wn'hm a shortar perrod If required by local Ordinance.q pre system is failing to protect grawna water,rhe sysfem must bs upgraded,replaced,or its use discontinued within the gee required by local ordinance.If an existing system is not failing as defined In law,and has at least two feet of design soil seperatton,then the system need not be upgraded,repaired,replaced,w its use disconUnued,notwithstanding any local orolnance met is more strict Thls provision does not apply to systems in shoraland areas,Wellhead Protection Areas,or those used in connection with food, beverage,and tonging establishments as defined in low. wq-wwi5ts4-31 Compliance Inspection Form for Existing SSTS 414108