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07/18/2011 17:32 7634988290 RUSTYS PERC TESTING PAGE 02 � � Minnesota Poliution Compliance Inspection Form � Control Agency �s SBTs 520 Lafayett�e�oad North �Is�� 0� �e Tre�rtn�ent Sys ( ) Sc.Paul,MN 55155-4194 InStruCtiUns Ofl pdge 7 Pa►�ce�number: 3311623330003 �' � For�c�Cal Trecking Purposes: � System stetus: � Compllent ❑ Nonwmpllartt X r / (based on e0 camplience�equliements) n��f � r0 Summ4ry Forr� � n r Property Information � ' � Property owner name(�): Douglas Reynolds __ — Property address: 75 CrXstal Creak Rosd,Orono,Mld 356 .. -- _ Propsrty owners address(N dlfferent): _.. . .. Counly: Hennepin Property awner phone: 812-325-2570 Permitting authority: City af Orono ^ pate system conetnicted: 5126�98 Re�son fior inspectior�: Property Transfer _ ,, System Destriptlon Approximately 1-1250 end 1-1000 gaNa�septic tanks, 1-1300 gallon Ifit etation and Approximetely Brief gystem desc►iptian: 630 scluere teet of mound rodcbed__ .— Local permil number. __ ...._,,, Number o(bedrooms: 5 Design flow rete: =83 Is the sysbem: In ShorelaRd erea? ❑Yes � No In Wellhead Protecdon Area7 []Yes � No An U.S. Environmental Protection System serving a Minnesata DepaRmeM Agency(EPA)Class V Injec�ion Well?�Yes � No of Heeth(MDH)licensed fecility? ❑Yes � No COI'YIPl�a11C@ $tdtUS(Based on siate requi�meMs–addidonal local requi�nts mey elso apply.) Based on the infoimation Qathered and reported on attacy�ed fortns,the comptience stetus of this system is(cd�erJc one): �Certficate of Complianoe–valld urrtil (3 years from date of report): 7/13/2014 ❑Nobice of Noncomplianoe-For Noncompli�nt sysbems: The reason for noncompliance is: �_ ._. Thl�noncompllant systsm is cl�awlfled aa(check one below): ❑ Imminent threat to public health 8 safety ❑FaIIInQ to protect pround water ❑ Not in compliance with operating permit C@rtifiCattOn (Completed form must be submitted to the local unit of govemment wlthin 15 days.) l hemby ce►ti(y lhsl afl the necessery infama6on hes been gathered to defiem►ine the c:om�liance stat�s of this system. No detem►Jnaflan of future system p�rfom►ance has been nor cen be mede due t�n unknown cnnditions during system constn�ctlon, passlble abuse af t►re system, lnedequate maintenanc�, w fufure wete+'usege. Name; Josep_h,J,,Olaan ._ Cer�tio�number: 1255_ , _ Business lioense neme end number: Rusty Olson'c soil�nd perr;ulation baeting Lic#810 _,_ or Name of locel unit of govemment: City of Orono , w_ \ SiQneture: `"'-' _,_ r Dete: 7l15l11 Requlred Attathments Inspedor Compleba:Thla Inspsction Report ls�psges long. Check compliancs fiorms�ched: �Hydraullc Perlortnanoe �Tank Ir�eqrity �Soll Separation ❑Operadng Permit Fom►(if appllcable) �5ystem drawinp/As-buiK drewlnp ❑A��meM o�a�y�i�u��►,c�m�t are a+rrero�t�wne��rea o�cni6 form �Sotl Bo�ng Logs ❑Abanda�meM fortn(M appro�riate) ❑Ottie�i�ortnation(Ilst�: _.._,-_ — ....... Upglide Requir6l►16n�8(de►fred from Minn.Stef.§115.55J M M►minent th�ef fa pubNc HesIM sn0 sal6ty(►7PHS)muat be upgrads0,replsce0,o� 2s uae disaontinued wllhin len maiMa of roca/pt oI tAle nonca or wllhin a ahorter period H raqube0 Dy lotal adlnenoe.1�fhe system rs/alNny!o ploloct prvund weler,the system must De upyl�010,replBCed,or I(8 u8e discontinued wiMin H1e llme roqullr0 Dy/oCY/o/dinenw,Il en exis8np syStsm IS nOt 1811Mp as deA�red in law,an0 nas a[feast two Aaet ol deslpn soi!sspeiatinn,then tAe sysMm nse0 not De upprsded,repeNed,�eplaced,a(ts use Olacontl�ued,nofwithatarxiinp eny locel adlnance thet Is mae sMrx Thia provis+on does not appry to systams!n shwe�end a�eea.Wehhead FhoMcUon Areas,or thoae uaed in connsction w!M Ibod, heverape,and lody'rnp estaDl/sAmsnfS a8 4MI1o0 rn lew. wq-wwists*-31 Compliance Inspection Form for Exlsting SSTS