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Property Address: 2900 Wear Circle <br />Business Name: Rusty Olson Soil & percolation Testing <br />1. Impact on public health — Compliance component #1 of 5 <br />Compliance criteria: <br />System discharges sewage to the <br />ground surface <br />System discharges sewage to drain <br />tile or surface waters. <br />Date: 8/25/2023 <br />Attached supporting documentation: <br />❑ Yes' ® No ❑ Other: <br />® Not applicable <br />❑ Yes" ® No <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 />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 />❑ Yes- ® No <br />Sewage tank(s) leak below their ❑ Yes` ® No <br />designed operating depth? <br />If yes, which sewage tanks leaks: <br />Any "yes" answer above indicates the system <br />is failing to protect groundwater. <br />Describe verification methods and results: <br />Kothrade Sewer & Water 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 8/23/2023 <br />(mmlddiyyyy): (must be within three years) <br />(See form 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-wwists4-316 • 4/28/1021 Page 2 of 4 <br />