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.03/02/20'11 17:52 7634988290 ��' RUSTVS PERC TESTING PAGE 62 'V . � i, � IHinnesota Pollution ��, �` Com liance Inspection Form � cor,tro� A9en�y p 520�afayetce i�oad Narrh E��t�� e $owage Troo�tm�nt 8ystents (SSY�) St.Paul,MN SS1S5-4194 Instructions on page 7 � Parcel num ( r: 0411723130�14 r For Local Trackfng Purpvses: System stat4s: � Compliant ❑ Noncompliant (b�sed on al�compliance requlrements) �ummar�y Porm Property Information Property ner name(s): Dwight Past Property dress: ^_ 2755 Deer Run Trail East,Orono, MN 55356 w _. „_„_ _ Property ner's address(�di�erent): Counly: enne in _ roperty owner phone: 612-747-0293 Permitting authprity: City of Orono ,w ____ Date sys m consiruct�ed: _ .0/'28199 Reaso�for inspectiorr Property T�ansfer .. ._.,_ System ription Approximately 2-1500 gallon sep�c tanks, 1-1500 gallpn Ifft st�tion a�d Approwmately 630 sque�'e Brief s desaiption: feet of mound rocicbed. , __ , . Local per it number: _ _ Number af bedroams: 5� Deslgn flow rate: _.83 �,� ., Is th�sy m: In Sho and area? ❑Yes � No In Wellhead Protection Area? ❑Yes � No An U.S Environmer�tal P ectfon System servinA a Minnesota Depertment Agency(EPA)Class V Inj ion Well?❑Yes �No of Heath(MDH)licensed facilii� ❑Yes � No CorrYpliance Statu��ea on staDe requiremeMs—additional local requiremenf�mey elso apply.j Based on the information ga ered and reporte�o�attached fonns,the oomplience status of this system is(chec4c one): � � cercitcate o�co�►��oe vali�urrtil (3 yeais fiorn dete of iepvrt): 3/1/2011 ❑NoticB of onoompliance For Nonoomplia►�sys�ems: The rea n for nonco Ifance is� Thl�noncompliant s tem is Clasalfled as check one below): ❑ lmminent threat to blic health&safety � F�ilfrtg to proteet ground vvt�ter ❑ Not In compliance wiih operating permit C@rtl�fiC8ti0�(Completed rm must be submitted to the loc�l unit of gove�nment within 15 days.) 1 hereby certify that all the n ssary inlformaHon has been gathered to detemilne the caompliarrce status of thls system. No dQte►mine6on of future syste perfv►mance has been nor can be made duuase to unla�own condiitiKwrs during system c�nstruction, possible abuse of the syste ,inadequate mafMenence, or future water usege. Name: Jose�h JAlson Certification number 1255 .__ W^ Busfneas license name end umber: Rus Olson's Soil and percailation testing Lic�810 0� Name af local unit of govem �nt: _ Citx of Orono wM _ ,.._ -..- Signatur ; �- Date: 3/2/11 Re ulre AttacFrment Inapectnr Complete:Thls Inspection RepnR is�pages long. C ck c ee�pliana�fOrnns ched: �Hydraulic Perfo►mance �Tank I�dey�ibr �Soil Separation ❑Operating Pertnik Form(iF applica ) �System drswi iglAs�uiR drawing ❑An 8seesemen[of eny local requiremanta that a►e diiferent from whel is required on this form Soil Boring Loga Abendonment fortn(if eppropriate) ❑Othe�i�ormatiun(lisi): � _...,.._,.........._- --- ------•--- -._._..._..._..._..._.._ UP9 e RequlremeMs derived lr�m Minn.Stat§�15.55)an i+nm�nent tn►�etto Pu�ic neam�and sarery prPrrsl musr oe uAp�aued,�epleced,or � Ra uae sconHnued wirhin!en fha olieoeipl o(this natice or x�'hin a sflarlrol'peMoO HreVulRW Dy loce/adlnanae.IPlhe system is tailinp to proted proun0 watsl,f sysfem must De upg ed,rep�eced,or its use diacon6nued within the t/ms r�ryulrsd Dy local oNln9nce,7 en eX�sHng syafem is not/ailinp 83 de/IneD�p law,an has at leasf two Reat o! ipn so/l sep�ratbn,Men tne system need not be uppraded,repaired,replaced,or its us�dlSconHnueC,notwhhatending any lxal o Ittance f�a1/s more sA'I 7Als p�vv/sWn doeas not epply fa sysfems in shoreland e�ees,Welllisad Profecffon A/eas,o�those used in conrrection wilH lood, DErv@ie ,and lodping estebl(sh enla es de6ned in lew. wa-wwist -31 Comp(iance Inspection Fnrm for Existing SSTS