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� Parcel number: 0411723340008 System status: �Compliant ❑ Noncompliant (as deteimined by fhis form) Nydraulic Performance and Other Compliance Compliance Issue #1 of 4 Date of observation: 10/11/10 Reason for observation: Property Transfer This form expires upon next inspection or in three years,whichever occurs first: 10/11/13 Compliance questions/criteria: (Required) Veri�cation Method*: (Optional) Check the a rn riate box (Check the appropriate box) Does the system discharge sewage to the ❑Yes � No � Searched for surface outlet round surtace? ❑ Performed hydraulic test Does the system discharge sewage to drain ❑Yes � No tile or surface waters? � Searched for seeping in yard Does the system cause sewage backup ❑Yes � No � Checked for backup in home into dwellin or establishment? ❑ Excessive ponding in soil system/D-boxes Do other situations exist that have the ❑Yes � No potential to immediately and adversely ❑ Homeowner testimony impact or threaten public health or safety ❑ Examined for surging in tank _�electrical, unsafe covers,etcJ? Any"yes"answer indicates that the system Is an imminerrt ❑ "Black soil"above soil dispersal system thr�eat to public health and safety. ❑ System requires"emergency"pumping ❑ Performed dye test Does the system pose a threat to ground ❑Yes � No � pther: Peterson Company water for any conditions deemed non- — rotective as deteRnined b the ins or? "Yes"indicates that the system is failing to protect ground water.If"yes'; describe the condition noted: *No standard protocol exists. This list is not exhaustive, in sequential ortler, nor does it indicate which combinations are necessary to make this determination. Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compliance Inspection Form for Existing Subsurface Sewage Treafinent Systems.Observations,interpretations,and conGusions must be completed by an inspector. Completed form must be submitted to the local unit of govemment within 15 days. Property owner name(s): Chistopher Smith Property address: 2943 Farview Lane,Orono, MN 55356 Property owner's address('rf different): County: Hennepin _ Phone: 952-404-3337 1 herieby cerfify that/personally made the obse►vations,inte►pretations, and conclusions reported on this form and that they are coirect. Name: Joseph J.Olson Certifiqtion number: 1255 Business license name and number: Rusty Olson's soil and perculation testing Lic#810 or Name of local unit vemment: City of Orono Signature: Date: 10/11/2010 wq-wwists4-31 Comptionce Inspection Form for Existing SSTS 4/4/08