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05/2512010 16:40 7634988290 RUSTVS PERC TESTING PAGE 02 / v .� M�nnesotaPollution Compliance Inspection Form Control Agency 5�O lafayette Fioad Nath Existing Subsurlace Sewage Tnatment 8ystoms (88T8) SC.Paul,MN 55i55-419a InsCructions on page 7 Paroel number: 3311823430017 For Local Tracking Purposes: System stetus� �Compliant ❑ Noncompliarrt (based on e/l complfance requi�emenfs) Summary Form Property Information Properly owner name(s): Kenneth Zagzebski ._ _�_,,.,.- Prpperty address: 2700 Copperview Drive, Orono, MN 55356 Property ovmers address(N sifleront): County: Hennepin Property owner phone_ 612-203-8473 Permitting authority: City of Orona Oate system consVucted: 11/21/03 Reeson for Inspecc:tion: Property Transfer System Descrlption Approximately 2-1300 gallon septic tanks, 1-1300 gallon Iffk stetion and Approximately 680 square Brief syetem descrlption: feet of mound rodcbed. Local permtt number: Number of bedrooms: 5 Oesign flvw rate: -83 b the sysbem: In Shareland erea? ❑Yes � No In Wellhead Protedlon Area7 ❑Yes � No An U.S. Environmental Protect(an System serving e Minnesota Department Agency(EPA)Class V InJectfon Well?�Yes � No of Heath (MDH) Ilcensed f�cility? ❑Yes � No Compliance Status(Based on atate requirements--8dditionel local requirements may elso apply.) 8ased on the information gathered end reported on attached fonns,the mmpllance stetuc of this system is(check one): �CeRlflcate of Complience–velid ur�til (3 yea�s from dete of report): 5/5/2073 ❑ Notice of No�compliance-For Nvncompliant s�rstems: The reason for noncompliance is� Thls noncomplfant system is classified as(check one below): ❑ Immin�nt threat to public health 8 safety ❑ Feiling to protect ground water ❑ Not in compliance with operating pennit Cel"t�fICBtIOf1(Compleied form must be submitted to the locel unit af govemment within 15 days,) I hereby certily that a/l the necessery Infonnadon has been gethered to delennine the cnmpllance ste�us of this system. No determinatiai of futu►e syatt4m perFannence has been nor cen be made due to unknown condlHans dudng system constrvct/on, possfbla abuse of the system,inadequate meintenence, oi future we�er usege. Neme= Joseph J.Olson Certlflc.8tlon numDer. 1255 Busineas lioense name and number: Rusty Olsan's soil end perr,ulation testfng Lic#810 or Name of locsl unit of gv�remment: City of Orono ^ Sig�ature: .. Date: 5J25/1 U �, —.,,. ..�...,..-..-,_.__, ..- ..,,...�._.,.....�_.�.w_ Requ4red Attachments In�pedar Complete: This Inspactlo� Report is f�paems long. Check ccmpliance fortna attached: �Hydreulic Perfiormance (]Tank InteQrtty �Soil Separatlon ❑Opereting Permlt Fortn(If appliceble) ❑Sy8tem drpWing/A6-bullt drawing ❑An assessment of any local requiroments thet are differenl From what is required on thl6 form �Soil Boring Lops ❑Abandonmont fortn(if eppropriate) ❑Other information(list): Upgiade Requlrements(deri�ed trom M/nn. srat §115.s5)ar,N„m/nenr�ruee�ro puarc neartn ano sanry prpHs�musr ne uppiad•a.rsaacsd,or 8s use diu�n6nued wifhln ten mOnlhB o/IBPB/pt o/M!s notlC�oI WfMlq a aNnrier psiiod if requbed by bca/adinance.II the syatem la fsiling to p�otecf gmund w�(er,ryre sysMm must Os uppra�ed,�ep�eced,o�Itr uae dlaconHnued w/Mln y�e pme r�pq�IroO Dy local obinancs.!f an exlsNnp system is not failing as daFined in lsw,end hea B!least Mro�eT WQespn tWl s�psrsUon,Onen Ois system oeed nol be upgraded,r�pslred,iep/eced,a!ts uae diacondnued,notwlMstandlRp any �a��ma„�mar r��,wre s�+cr, rnrs v�waron aoss nor a�ry ro sysrsma��Snore��,a 8,�8 Wal�head P�otecfion Aiees,w those uaed!n conqectlon wllh�pp0, Oeve+eQe,and lod9iny establishmenfs ea defined/n lew. wq-wwlsts4-31 Compliance Inspection Form jor Exlsting 55TS