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09/16/2010 16:16 7634988290 RUSTVS PERC TESTING PAGE 02 / <br /> ✓ <br /> ' � Minnesota Pollution Compliance Inspection Form <br /> Control Agency <br /> 520 Lafayette Road North �stlryr Subsurlace Ss�vvage Troat�nent Syst�ms (SSTS) <br /> St.Peul,MN 55155-4194 Instructions on page 7 <br /> Parcel nwnber: 051 1 7231 20021 For Local Tracking Purposes: <br /> System status: � ComplieM ❑ Noncompliant <br /> (based o�►ell�ompllance requlr�ments) <br /> Summary Form <br /> Property Information <br /> Property aiwrter neme(s): CartGon H <br /> propetry addrsss_ 3485 Christine Drive,Ororw,MN 55359 <br /> Ptc�pe�ij►vwne�'s eddress(if dilfwonq: „__� <br /> CcuM�r: Hennepin Properiy owner pho�ne: 612-38�0-8118 Pe�mitdrtg eutFwrity: Cit rLof Orono <br /> Date system constructed: 77/16/89 Reason fo�inspecdon' , Property Transfer <br /> System Descriptlon <br /> Ap�rCaclmstely 2-1 SW gallori septic t8nk8,1-15Q0 gallon lift stadon end Appro�aimately 630 aquare <br /> Brief system description: feet of mound roc9cbed. <br /> l.ocal pe�mlt number ____.. Numbe�of bedrooms: 6 Design flow rate: .83 <br /> b tlw sy�6am: <br /> In Shor�e�d aree? ❑Yes � No In WeQhead Prvtectlon Area? ❑Yes �No <br /> An U_S.Environmer�tel Protection System serving a Minnesota Departrner�t <br /> Agency(EPA)Class V 4njecUon Well?�Yes � No oi Heath(MOH)licansed f�cility? ❑Yes �Nv <br /> C0111p�tdllCe St8tU5(Besed on SFat�requiremer�ts–addilional locel requfremar�ts may elSfl apply.� <br /> Based on tho information gathered end repoRed on atteched fortns,the�mpllence steius of this system is(chedc one): <br /> Q�CerfHica�e of CompliBnCe–valid until(3 yee►s!ra►t da6e af iepo►Q: ' �I14J2010 <br /> ❑Naboe Of Noncomplience-For Noncomp�ieM sy�ems: <br /> The�son For nonoornpl�r�Ce is: <br /> This noncompllant syateim I�clas�lfled as(check one bolow): <br /> ❑lmminent threat to public health&safet}r ❑Feiling to protect pround water ❑Not fn mmplianCe with ope►ating nermft <br /> C@ft�f4C8t1011(Completed form mu�t be submitted to the locel unN afi gavemment wlthin 15 days.) <br /> 1 hereby ce►tify thst sll the ne[�esssry infvimetion hss bee►►gsthe►ea to de(�em�►re tt►e co/►Iplia/x�e staius o!thls system_1Va <br /> detemy��an of futu�p sysllam peifivrrnance has been r►o�can be made due to uMaiow»aa►di�ions du►Ing system aonstn�ctlon, <br /> possible abus+e of dl►e system,inadequa�e meintenanoe.a�r fidu►e water u�8ae- <br /> Neme: Joaeph J OI� Certific�tiori nurt� 1255 <br /> Business Ifcenae name and number Rusty Otson's soil and perailatlon bestfng Lic i�810 or <br /> Neme of local unit af govemment C of Orono ..— <br /> Signatune: DaLe: 8V15J10 <br /> Requi�ed Attachments Inap�ctor Completie:This Inspectlo�Report is�pape�long. <br /> Ct�cic compliance foems atmched: �����wertormence Q�Tar�c�ntegr9ty �so��sepa�adoa D���'�9 Po^„a Fom,(� <br /> aPP�b�) 0��draxring/As�Dullt drawin9 ❑An s�nenl of arry local nequlrort�s thet are dMls�erit iram wAat I�required on thi6 <br /> fOrrrl �SoN Borin9 Lops ❑Abandonmord 1am(If appropria�) ❑ONIer IrrMnnatbn(1'st): <br /> UP8f8d@ Requi�mwtb(deui�d fiOm Mlnn_Stat§115,551 M tmminent M►wt to DVOIIc heeAHr srrd sall�b fl7nHS)must Ae uP9��.�spec�Gl or <br /> Rar use dle�vntinustl w�IhM ten monHrs of rettlpf o/M�s notloe or rriMln a sAa/[er Derlod�7►e9uhsd�Y bCel ordinencs.A'�Je syaUovn is f9ilinp to D/obBd�ur�n0 <br /> wetsr tlw sys►e+n muat bs upylsae0,�pfeoad,or ita uss 0(eoonMwed w�ln fA.tlmo►eCul�6d by bcal aO/n�noo,If en exLstiny BY�w�is rrnt faiNnp es Oelb+ad in <br /> lew,en0 Aas at l�rst nro Imat ot�sign sadl s��sdlo�.Ghen ehs ayanrm nee0 nd be upg,adetl.�ah�d��el�aoed,or fts u.st dlsoontinueol.natwlthaRenGing e►►y <br /> lacsl ordlrrance Met�S mo►s a6id 7Ats p�vlsl�on doea not appryr 90 sysOsms!n aho�afend areaa.NbN4hoad PmtecE�on Msas,a those ussd M conrtectlon wi�faoq <br /> bAYMiGe,N�d lodg'ag effisDl�f►IIIN►!8 99 denned in law. <br /> wq-wwlsts4-31 Canpliance/respevccfon Form for EkisNng 5575 <br />