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66I27/2009 12:39 7634988296 � i � 1� RUSTYS PERC TESTING PAGE 02 . �. �;... ..._----- �, l�". �,�� Mi�nesota Pollution � �ompliance inspection Form Control Agency 520 Lafayette Road North Existlog Subsurtace �ewage T�eatnient Systems (SSTS) Sc.Paul,MN 55�55-�194 Inst�uctions on page 7 Paroet number. _ � F�r Local Tracking Purposes; Syst�m etetus; � Complient ❑ Noncompliant (based on ell canpllence requirements) Sumntery Forn� Property Information Propenp owner�eme(s): Catherina Johnston _ _ Property eddress: 940 Brown Roed S, Orono, MN 55381 _ , Property owners address(if diReront): _ CouMy: Hennepin Property owner phone: 612-770-1799 P��rnik'xi�:,�authority: Clty of Orono Date system consUucted: 8/271'89 Rea�n for inspedion: PropeR�Trensfer _ , System Description Approximately 4-1000 gellon septic tenks, 1-1250 oallon Ifft stativn and Approximetely 830 square Brief system description: feet of mound rodcbed. Locel permit number: , NumDer of bedrooms: B Deeign flow rate: .83 _ Is the sr�m: In Shoreland a�ea? �Yes ❑ No In Wellhaad PrMectlon Area? ❑Yes � No An U.S. Environmentsl Protection System serving a Mlnnesot�Department Agency(EPA)Class V Injection Well?❑Yes �No of Heath(MOH)licensed facility� ❑Yes �No COR1p�f811Ce $t8tU5(9ased on state requirements–additional local requiremerns mey also apply.) Based on the information gethered and r�ported on attached forma,the wmplienoe 6tetus af thls system is(chec;k one): �Certiflcate of Compliance–velld until(3 y�a�s frt�m dete of report): 6/26/2012 __ ❑ NaUoe of Nonwmpliance-For Noncompllant syslems= The reason iur nonmmptianoe is: �,,,. _._—. _�, Thls noncompliant 9y�tem(s classlHed as(check one below): ❑ Imminent threat to public health&safety ❑ Failing to protect ground water ❑ Not in compli�nc�with operaUng permit C@1't�f�Cdt1011(Completed form must be aubmitted to the lacel unit of govemmeM within 15 deys.) !hereby ce►tlfy thet ell the necessary Inhom►etion has been gethered ta delem►ine the car+pliance status of this system. No detem►ination of Iuh�re syal�em performence hes been nor cen be made due to unknown condiHons during sysfem constructivn, passible abuss of ths system,inadequate rneiirtenance, or li�tuie water usaBe_ Neme: Jvseph J.Olson Certificetion number: 1255 Business lioense name and number: Rusty Olscm's soil and perculation leating Lic#610 ____ c� Neme of locel unR of govemmerrt_ Clty of Orono , Siqneture: � Date: _ 6/27ro9� Required ttachmentS ��ao�comp��:Tnis insr�ectio� RePort�s�paaes io�e. CheCk COmpll��ca foR11s att8cheil: � Hydraulic PerfoRnenoe ❑Tpnk InteQrlty �Soil Sepbrtttlon ❑Opsra6ng Pe►mit Fom1(K app��Cebb) ❑Syatem drawing/As-built drawiny ❑An aeses�ment of eny locel requiromenL9 that are different from what ia requlrod on this fortn �So�l BOring Logs ❑Abendonmer►t torm(if approp�lete) ❑Other Infortnation(list): Upgrade Requlremer�a(d9rlred Avm Minn. Stek§11 S.�6)An/mmUrtnt threat to puWfc healfA artd seFsly(ITPIiS)must pe upgreded,�aacad,or (!s uae diemntinued wilh/n Mn montl►s of rsaslpt o/Mls noQbe a wifh/n a shorter pe►iod ilroquhed Dy local adlnartw.H the aystem!s falling M pm[sct proun0 we(er,tRe system must De upprsce0,�Dlacod,or Ua uae dfemnfh,ued wlMrrm tlie nms isqWrsd by bcol ordMonce.ll en e,�IsHng system la not lepiny ea deAned in law,6►�d has at leest two/eef ol desipn aoil separadon.llrsn Ms sysMm rfe�sd not De upp►aded,►epeNed.�epeleced,or ffs use d/scontMued,notwKhatendlrrg eny bcal adlnance�het!e mo►s sh1d. Thia pwiaian doss rtot appry to syatrma In sAaelend artree,Wslfheed ProlscHon Ansa,o/d�ose uaed in connection wNh food, beverape,end lodp�inp e�eWisnmsn�a sa a�Nr�eOln lew. wq-wwlsts4-31 Comp(fonce Inspecclon Form for Existing SSTS