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Property Address: _1125 Willow Drive N. _ <br />Business Name: Rus Olson Soil &percolation Testing <br />1. Impact on public health — Compliance component #1 of 5 <br />Compliance criteria; <br />System discharges sewage to the ❑ Yes" ENO <br />ground surface <br />System discharges sewage to drain ❑ Yes` M No <br />tile or surface waters. <br />System causes sewage backup into ❑ Yes* ® No <br />dwelling or establishment. <br />Any "yes" answer above indicates the system is an <br />imminent threat to public health and safety. <br />Describe verification methods and results: <br />Visual. Nothing was found <br />Date: 3/3/2022 <br />Attached supporting documentation: <br />❑ Other: <br />0 Not applicable <br />2. Tank integrity — Compliance component #2 of 5 <br />Compliance criteria: <br />System consists of a seepage pit, <br />cesspool, drywell, leaching pit, <br />or other pit? <br />Sewage tank(s) leak below their <br />designed operating depth? <br />If yes, which sewage tank(s) leaks: <br />[--]Yes* ED No <br />❑ Yes' 0 No <br />Any "yes" answer above indicates the system <br />is failing to protect groundwater. <br />Describe verification methods and results: <br />Elmer J. Petersom Company pumped the tanks. <br />Attached supporting documentation: <br />❑ Empty tank(s) viewed by inspector <br />Name of maintenance business: <br />License number of maintenance business: <br />Date of maintenance: <br />Existing tank integrity assessment (Attach) <br />Date of maintenance 3/1/2022 <br />(mm/dd/yyyy): (must be within three years) <br />(See fora instructions to ensure assessment complies with <br />Minn. R. 7082.0700 subp. 4 B (1 )) <br />❑ Tank is Noncompliant (pumping not necessary -explain below) <br />❑ Other: <br />https://www.pca.state.mn.us 651-296-6300 800-657-3864 • Use your preferred relay service + Available in alternative formats <br />wq-wwists4-31b • 4/28/2021 Page 2 of 4 <br />