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'��'°Y����g'�' ` Street Add �
�gg0 �= h�ailing Address:
2150 Kell y Parkway P.O. Box 66
Orono, M 55356 Crystal Bay, M�Y 55323•OOE
95d-�y -y600
To Cu.-rent Owner: Addre s: �4' � S �`� �;c�� �
City Ordinance 199 requires that each existin�on-site sewa�e treatme t system in Orono be�inspected every two yean.
The on-site sewage treatrnent system at the above address has been in ected and appears to fall into the categories checked below.
SYSTEM CONFORI�tITY (1-31: I
1 '�CODE SYSTEM" An ISTS which mccts all thc�ocapon,dcsign and nstruction scandards oCthc current Otono l�funicipal Codc.
2 "COI�iPLIANT SYSTEM" An ISTS which docs not mcct all ttnc lo ion,dcsign and corutruction rtandards of thc currcnt Orono hiunicipal
Code but docs mcet thc thrcc foot scparation requircmcnt or Rvo foot ct uinment for rystcros installcd 1996 or eariia,and which is not failino or
an imminent thrcat to public hcalth or safcry.
3 "NON-CO�iPLLANT SYSTEM" A prohibitcd ISTS;an[STS loc cd within a dcsignatcd (00-ycar flood plain,any ISTS which may
or may not mcct all thc Iocation,duign,or conscruction standardt af currtnt Orono Municipal Codc and which is failing for any tcason;and
any ISTS with less than t}ucc fcet of unsaturatcd aoil or sand bccwccn e dis�ibution devicc and thc limiano soi]charactcriscics,
TANK C0�IDITION(�-.7�: �
Tank inspection indicates: '
OPumpout not needed at this time.
6 Septic[an.�cs must be pumped out thu year (city code requires ks to be pumped out once every 3 yearsa
Tank was l�st pumped °I-(,-CU � .
i�lake sure se tic tanks are um ed throuah manhole and not hrouah�vhite ins ection i es.
This allotiti�s for the proper cleaninQ.
7 Inspection risers missin�tanks could not be inspected. Ins ction risers(4"dia.pipe) must be installed in each tank.
DRAI�tFIELD CO�IDITION($-JO): �
8O Drainfield is dry,no surfacing evident.
9 Some evidznce of surfacin�,not critical yet. �
10 Drainfield is saturated and visibly dischargin�unercated efflu nt to the surface. Contact the City Inspector
immediately.Repairs must be completed within 90 days.
CO�iENTS: Gc��.��-:C�Gi f00�s �F� ��11- �cJc�' <�� f1��1��1��( C � -�;�St'
C'ti�1 � �C S�`��
� a� o�.. a r��:��.-��
�-�6 -�3 �h2�-
Da,e oC Inspcction
I�fatt Boltccman - Scptic Systcm Insptctor
I�otc: In thc cvcnt that atiis irupccaon rcport is uscd to suisfy the rcquircmcncs Cor a mo �e orolhcr rransfcr of propc ,ry,be adviscd that this rcpoR docs r,otg�=-���=
orcc�ify�hatanc�cistingrysccmwilicontinuctofuncaonproper]y,bctismcrclyanopinio ofthcaCcquaryofthcsyst�nundcreur.zntconditionsbascdonchcaYu���'
infocmatian.
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`�k'ESH�4`' 2150 Kelley Parkwa P.O. Box 66
Orono, MN 55356 Crystaf Bay, MN 55323•0066
Owner: /�ar�� � O��So r� Address:_ 4`� S5 QAyS,�� RJ .
City Ordinance 199 requires that each existing on-site sewage treatment syst m in Orono be inspected every rivo years.
The on-site seivage treatment system at the above address has been inspected and appears to fall into the categories checked below.
SYSTEM CONFORMITY 1-3 : �
1 °CODE SYSTEM�� An ISTS which meets a11 the location,dzsign and construction dards of the currznt Orono bfunicipal Code.
2 '�CO�IPLIANT SYSTEM° An ISTS which does not meet all tha location,desi and construction standards ofthe current Orono Municipal
Codz but dozs meet the three foot sepazalion requirement,and which is not failing or i.,,,.,��ent threat to public haalth or safety.
3 "NON-COi�IPLIANT SYSTEM" Aprohibited ISTS;an ISTS located within d�.signated 100-year flood plain,any ISTS which may
or may not mzet all the location,design,or construction standards of the cucreat Oro o blunicipal Code and which is failing for any reason;and
any ISTS with less than three fezt of unsaturatzd soi!or sand bztween the distribulion device and the limiting soil charaderistics,
TANF:CONDITION(�-10): � .
Tank inspection indicates: -
� Pumpout not nzedzd at this time.
� Tanl:must be pumped out this year (city code requirzs tanks to be pumped out every 3 ears. Tank was last pumped � 7' 3�—q�),
7 Solidz accumulation in tanks is at a critical a critical level. Tanks should be pumped ou as soon as possible.
8 S}�stem is discharging to the surfacz. Tanks must be pumpzd out within 48 houn to el' ' ate surfacz discharge.
I Inspeceion riszrs missing-tanks could not be inspected. Inspection riszrs(4"dia pipe) ust be installed in each tanlc at next pumpout If tanks
have not bezn pumped out within the last three years,they should bz pumped out now.
1� Inspe�tiun pipz is locatzd directiy over tank ba&lz(does not give accurate mzuuremzn of solids accumulation). If tanks have not been pumped
out within the list three yean,thzy should be pumped out no�v.
D IELD CO�tDITION 11-14 : �_
11 Drai�zld is dry,no surfacing evidznt
12 Some zvidznca oFsurfacing,not crilical yet � � ' '
13 Drainfield is saturated and visibly discharging untrzatzd eHluent to the surface. Contact e City Tnspzctor immediately.Repairs must be
completed�cithin 90 days.
1� Dra'mfield esczni and condition unknown.
COM�NTS: 5 �� �5 o K
.
�-�l—o � �
Date of Inspection Septie System Inspector 4
Nota: In the event that this inspzccion repoR is used to satisfy the requuements for a mortgage or otfi transfer of property,be adviszd tbai this report does not guaranY�e
ot certify that an esisting system will continue to function properly,but is merely an opinion of the equacy of the systecn under current conditions bazed on the availabl�
informalioa
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CITY OF ORONO O
Municipal Offices
Post Office eox 66
Crystal eay, MN 55323-0066 � � ON-SITE SEWAGE TREATMENT
r�), INSPECTION REPORT
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9kESH0 �
ll��"1�r�� ��l����s� ` C�,
Owner: Address: � �C5 S�f)-(. �� -.5 J� �.� 1
' ���SS Dates• � '
Permit # s• . �3 J� con ractors• �/t,�/ ��c:2 �/1e,5,
City ordinance nunber 100 requires that each on-site sewage tr'eat t system in Orono be inspected on a regular basis.
The on-site seuage treatment system at the above address ha be inspected and appears to fall into the category
checked belou.
(This is�an existing system [ ] new constructi n)
SYSTEM CONFORMITY (1-3):
1 "CODE SYSTEM��-A system which meets all the location, de ign, and construction standards of the current City
Codes, and which is operating satisfactorily by treating and disposing of the entire current sewage input
Without discharging any pollutants into ground or s rfac waters.
2 "CONFORMING SYSTEM"-A system uhich does not meet all he ocation, design, and construction standards of the
current City Codes, but uas installed according to he c de in effect at the time of installation, and Which
is operating satisfactorily by treating and disposing of the entire current sewage input without discharging
any pollutants into ground or surface waters.
3 "NON-CONFORMING SYSTEM"-A prohibited system; a syste loc ted uithin a designated 100-year floodplain; any
system which may or may not meet all the location, des gn, and construction standards of the current City
Codes and which is failing for any reason; and any yst with less than 3 feet of unsaturated soil or sand
between the distribution device and the limiting soil ch racteristics.
(7he limiting soil characteristic �j has or [ ] has not been identified at this time. If the limiting soil
characteristic has not been identi�fied, this classificati n may be subject to revision.)
TANK CONDITION (5-10):
inspection indicates:
5 Pumpout not needed at this time.
Solids accumulation in tanks indicates they should be pump d ou this year to help prevent future problems.
7 Solids accumulation in tanks is at a critical level. Tank sho ld be pumped out as soon as possible.
8 System is discharging to the surface. Tanks must be punped out uithin 48 hours to eliminate surface dischar�e.
9 Inspection risers missing-tanks could not be inspected. Inspec ion risers (4" dia, pipe) must be installed in each
tank at next pumpout. If tanks have not been purt�e out within the last three years, they should be pumped
out now.
10 Inspection pipe is located directly over tank baffle (doe not give accurate measurement of solids accumulation).
tf tanks have not been punped out within the last th ee y ars, they should be p�xnped out now.
DRAINFIELD CONDITION C11-14): i
(r���field inspection indicates:
_1a' Drainfield is dry, no surfacing evident.
-T2 Some evidence of surfacing, not critical yet.
13 Draintield is saturated and visibly discharging untreated ef luent to the surface. Contact the City Inspector
immediately. Repairs must be completed uithin 90 da�s.
14 Drainfield extent and condition unknoun.
LIMITING SITE FACTORS (slope,setbacks,etc.): �--�
POTENTIAL FOR SYSTEM FAILURE (depends on soils.water table,etc.) �
COMMENTS:
Date of In pection S ptic ystem Inspector
Note: In the event that this inspection report is used to sati�fy t e requirements for a mortgage or other transfer of
property, be advised that this report does not guarantee or ce tify that an existing system uill continue to function
properlyi but is merely an opinion of the adequacy of the syste under current conditions based on the available
information.
This report must be kept on the pre�nises with t�e s tem locati�n and pumping records.
WHITE COPY/Inspectors Fi�e I YELLOW COPY/Homeowner
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.t � ,�'�.�1���g'�;k� Street Address: Mailing Address:
'q$EgKO�' 2750 Keiley Park ay P.O. Box 66
Orono, MN 5535 Crystal Bay, MN 55323-0066
Owner: _�(i c-(1� �C\�1 h S O %� A dress: 4455 Bayside Rd.
Permit #'s: 1917, 7085 Dates: 8/20/68, 8/3/83 C ntractors: Ed Heins, Widmer Bros.
(This is [xl an existing system [ ] new constructio ) .
SYSTEM COMPLIANCE (1-3) : 1
� Code System: Meets or exceeds current City sta dards in all respects relating to design,
construction, and location. Appears to be operat'ng properly.
2 Compliant System: Does not meet all current Ci y standards for new construction, but in
most respects appears to be designed, located, a d constructed in accordance with previous
codes and is functioning properly.
3 Non-Compliant System: System may or may not meet current City standards for design,
construction, or location, but is failing to p operly treat and dispose of the current
input; and any system with less than three feet o vertical separation between the bottom of
the drainfield and the saturated soil level.
(The saturated soil level [ x) has or [ ] has no been identified at this time. If the
saturated soil level has not been identified, this clas ification is subject to revision.)
T K N 5
5 Pumpout not needed at this time.
6 Solids accumulation in tanks indicates they shoul be pumped out this year.
7 System is discharging to the surface. Tanks must be pumped out within 48 hours.
8 Inspection risers missing-tanks could not be ins ected. If tanks have not been pumped out
within three years, they should be pumped out and risers installed now.
9 Inspection pipe is located over tank baffle-can ot measure solids accumulation. If tanks
have not been pumped out within three years, they should be pumped out now.
(During the last septic tank Maintenance Pumpout the nks [ ] were or [X] were not coafirmed
to be watertight by the licensed pumping contractor. If the tanka were not confirmed to be
watertight, this classification is subject to revision.)
DRAINFIELD CONDITION (11-14) : 12
11 Drainfield is dry, no surfacing evident.
12 Some evidence of surfacing, not critical yet. Re air is not required at this time.
3 Drainfield is saturated and visibly discharging u treated effluent to the surface. Contact
the City Inspector immediately. Repair must be c mpleted within 90 days.
14 Drainfield extent and condition unknown.
ST M .) : high
COMMENTS: Heavy July rains may be contributing to the drainfield overloading. The discharge is
occurring from the 2nd drop box to the east end of th trench. The owner claims that this line
was abandoned when the trenches were added in 1983.
�����
Date of Inspection Septic ystem Inspector
Note: In the event that this inspection report is used to satisfy the requirements for a
transfer of property, this report does not guarantee that an existing system will continue to
function properly, but indicates the operation of the s stem under current conditions.
Telep6one (612) 473-7357 • 473-0510
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CITY OF ORONO O
Municipal Offices �
Post Office Box 66 '
Crystal Bay, MN 55323-0066 � � ON—SITE SEWAGE TREATMENT
� INSPECTION REPORT
���k o4�
ESH
Owner: ///,�YK� ��1't�l�� Address: ��l
.
^ � ��S
Permit #'s: Dates: ���'� Co ractors:
City ordinance number 100 requires that each on-site sewage treatm nt system in Orono be inspected on a regular basis.
The on-site sewage treatment system at the above address has be inspected and appears to fall into the category
checked below.
(7his is p(1 an existing system [ 7 new construction>
SYSTEM CONFORMITY (1-3):
"CODE SYSTEM"-A system uhich meets all the location, design and construction standards of the current City
Codes, and which is operating satisfactorily by treating and disposing of the entire current sewage input
without discharging any pollutants into ground or surfac waters.
2 "CONFORMING SYSTEM"-A system which does not meet all the ocation, design, and construction standards of the
current City Codes, but was installed according to he ode in effect at the time of installation, and which
is operating satisfactorily by treating and disposi g of the entire current sewage input without discharging
any pollutants into ground or surface waters.
3 "NON-CONFORMING SYSTEM"-A prohibited system; a syste lo ated within a designated 100-year floodplain; any
system which may or may not meet all the location, des'gn, and construction standards of the current City
Codes and which is failing for any reason; and any syst m with less than 3 feet of unsaturated soil or sand
between the distribution device and the limiting soil ch racteristics.
(The limiting soil characteristic �has or [ ] has no been identified at this time. If the limiting soil
characteristic has not been identified, this classificat on may be subject to revision.)
TANK CONDITION (5-10): �
T�q�c inspection indicates:
C51 Pumpout not needed at this time.
6 Solids accumulation in tanks indicates they should be pumped o t this year to help prevent future problems.
7 Solids accumulation in tanks is at a critical level. Tanks sh uld be pumped out as soon as possible.
8 System is discharging to the surface. Tanks must be pumped ou within 48 hours to eliminate surface discharge.
9 Inspection risers missing-tanks could not be inspected. Inspe tion risers (4" dia. pipe) must be installed in each
tank at next pumpout. ]f tanks have not been pumped ou uithin the last three years, they should be pumped
out now.
10 Inspection pipe is located directly over tank baffle (does no give accurate measurement of solids accumulation).
If tanks have not been pumped out within the last three ears, they should be pumped out now.
DRAINFIELD CONDITION (11-14):
Drp{nfield insPection indicates:
(11 Drainfield is dry, no surfacing evident. !
'2 Some evidence of surfacing, not critical yet.
13 Drainfield is saturated and visibly discharging untreat d e fluent to the surface. Contact the City ]nspector
imnediately. Repairs must be completed within 90 d ys.
14 Drainfield extent and condition unknown.
LIMITING SITE FACTORS (slope,setbacks,etc.):
POTENTIAL FOR SYSTEM FAILURE de ends on soils water table etc. :
COMMENTS:
�
a
Date of Inspection S ptic System Inspector
Note: In the event that this inspection report is used to satisfy he requirements for a mortgage or other transfer of
property, be advised that this report does not guarantee or certif that an existing system will continue to function
properlyi but is merely an opinion of the adequacy of the syst under current conditions based on the available
information.
This report must be kept on the premises with the ystem loc=tien and pumping records.
WHITE COPY/Inspectors File YELLOW COPY/Homeowner
li �
On the North Shore of
Lake Minnetoyzka
ON-SITE SEWAGE TREATMENT
INSPECTION REPORT � POST OFFICE BOX 66
1335 S. Brown Rd.
� � � Crystai Bay, MN 55323
473-7357
OWNER ���✓/� ,l`�11�' � ADD ESS �Z75�— .(.�1i,SX�� l��
.
PERMIT NO.'S. � �U DATES ' °�� CONTRACTORS ��l �����
City Ordinance No. 210 requires that each on-site sewage treatment syst m in Orono be inspected on a regular basis.The onsite sewage
treatment system at the above address has been inspected and appears to fall int the category checked below.
(This is �an existing system ❑ new construction) '
J�1 � Meets or exceeds current City standards in ali respects relatin to design,construction,and location.Appears to be operating
�� properly.
� 2 Does not meet all current City standards for new constructi n (1978 Codel but in most respects appears to be designed,
located, and constructed generally in accordance with previou codes. System appears to be functioning properly; no major
upgrading of the system is required at this time.
� 3 Does not meet current City standards in many respects elati to design, construction,or location.Appears to be operating
adequately at this time, but has a relatively high potenti I for future problems. No major upgrading of system is required at
this time.
� 4 System may or may �ot meet current City standards for desi ,construction or location, but is failing to properly treat and
dispose of the current input,and is endangering a water suppl , or is a source of pollution to surface or groundwaters,or is
creating a safety hazard,or is otherwise creating a public nuis nce.Please contact the City Inspector to discuss system repair/
replacement procedures. If drainfield replacement is necessary soil testing will usually be required,a�d a design and site plan
must be submitted for review.Your contractor must obtain a p rmit before work is started.
SYSTEM CONDITION ( m Checked items may require your action)
Tank inspection indicates: ❑ nspection pipe is located directly over tank baffle.(Does not
�Pumpout not needed at this time, ive accurate measurement of solids accumulation.) If tanks
❑ Solids accumulation in tanks indicates they should be pump- ave not been pumped out within the last three years, they
ed out this year to help prevent future problems. ould be pumped out now.
❑ Solids accumulation in tanks is at a critical level. Tanks Drainfi Id inspection indicates:
should be pumped out as soon as possible. � rainfield is dry,no surfacing evident.
❑ System is discharging to surface. Tanks must be pumped ❑ ome evidence of surfacing,not critical yet.
within 48 hours to eliminate surface discharge. ❑ rainfield is saturated and visibly discharging untreated
❑ Inspection risers missing—tanks could not be inspected. ffluent to the surface. This condition may require replace-
Inspection risers (4" dia. pipe)must be installed in each tank �I ent or additions to drainfield. Contact the City Inspector
at next pumpout. If tanks have not been pumped out within , i mediately.Repairs must be completed within 90 days.
the last three years,they should be pumped out now. ❑ rainfield extent and condition unknown.
SITE CHARACTERISTICS:
Limiting Site Factors Potential for System Fai ure Site Capabilities for
❑ Slope (depends on soil types, ater Future Expansion
❑ Soil table,and system ondit on) ❑ Adequate
❑ High water table ❑ Low �Fair
❑ Lotsize �Medium ❑ Poor
❑ Lake,wetland,or stream ❑ High ❑ Inadequate
❑ Drainage ❑ System is ca sing isible
surface discharge.
COMMENTS:
�"� 7-�� - `
Date of Inspection eptic SYstem Inspector
Note: In the event that this inspection report is used to satisfy the requiremen s for a mortgage or other transfer of property,be advised that
this report does not guarantee or certify that an existing system will continue function properly,but is merely a�opinion of the adequacy
of the system under current conditions based on the available information.
This report must be kept on the premises with syste location and pumping records.
WH�TE COPY/Inspector's File GOLD COPY/Homeowner
� � `.
C IT of ORONO
, � � �
� Municipal Offices
�� G~ Street Address: Mailing Address:
�`�.FtEs��g'� 2750 Kelley Parkway P.O. Box 66
Orono, MN 55356 Crystal Bay, MN 55323-0066
December 12, 2005
W of Minnetonka Inc. j
Peter W. Johnson
4455 Bayside Road
Maple Plain MN 55359
Dear Mr. Johnson:
I am writing in regards to the above addressed prope y, tax parcel number 06-
117-23-21-0002. A septic system certification was a empted on July 22, 2005 by
Rusty Olson's Soil and Perc. Testing. The existing s stem does not meet the
required three foot separation to groundwater nor are he septic tanl<s watertight.
�'he existing system is classified as a failed systezn d must be updated by
August l, 2006. The inspection also indicated that th system is hydraulically
loaded. This indicates breat potential for effluent co ing to the surface of the
�round.
Please malce the necessary arrangements to brin�the ys�em inta complian�e.
You will need to contact a septic designer to do soil orings, perc. tests, and a
design based upon the number of bedrooms in the ho se. You may then brin�the
design in for City approval before getting bids from s ptic installers. A complete
list of designers and installers may be found at ww-��,-. ca.state.mn.us then clicl: on
wastewater division.
If youu have any questions regardin� this matter pleas feel free to call.
Sincerely,
;.
� ; ,, ,�;'�f . �� '
%1.i..,�.,��y,�._.� �,,�.,�:-`�
Willie Gibbs R.S. � ��
ISTS Manager
�'e➢��a�o��(9�?)2��-4600 m �a?� 95'�j'��9-4a���u
@°!'!S'W'.Cfl.�?'OI9t3.t�H9u,39
. 07/`26/2005 09: 55 7634988290 RUST S PERC TESTING PAGE 61
� • ,
FAX COVER SHEET
Rusty Olson's Soil And Peroc. Testing
11481 Riverview l�bad NE.
Henov�er, MN 55341
Oflice 763-498-8779 ��
Fsx 763-498-8290 ��,� "�
I,� � h; ����
�
SEND TO I ]�
ComPer►Y neme � ,� 1
C' of Orono
Attentlon � ��
Wille Gibbs � � �
O�ice location C � � �,�,, y ,�'C
r, F �/`;/�./�P '�~ j.��
'�..r-� ��l 7 A—{ � ,c��C
Fex num0er Pi �i. � (3 5 �i
952-Z49-4616 . 7��},"n 'S J 3
���e � ��r,� s��.�
�'�`' ���,,�.-�f;. C�-
� lMgent ❑ ReplY ASAP ❑ Plwso com� _ .�....r U For yvur lnlomwtion
Totel pages,includirtg cov�r. 6
COMMENtS
.._ Septic oert for 4455_bayside Road,Please file_ ---
........................:.:.......__-----------................._..._..__...._.............._....._........__..............._...._..._..._...._......._____._... ...--------..----------------------._..__._._....._._..._..._........................
__...Ifyou.have.any_yuestions,please call_._Thank You._..._...........__._.....-.-.- .---._...-.---.-.-.----.__.__._._..._.___..._____._._..._..._.�.__._...._
_...__......_..._...............�....................,...:.,.....,...:.:.:.,.,:.:....:.�:.:..:....:...:..:...:..........:....;........._..._......................_._.........._....._..
.._____..._..�..................._._._.__._.__..._.__..._......,._...._..:._.....:._._..._:__._..._...__...____._..._..._._...__.,._....,....._._.__�...�...,....._......_.........,._.........._......_._....__..._____.........._..._...-----------------------
..,...........:.,,.,�...................._..�.....�._..._.........__...._......_......_._........_____--------------------...---...----+
. 07i26/2805 09:55 7634988290 RUST S PERC TESTING PAGE 02
RUSTY OLSON'S SOIL AN PERC. TESTING
11481 Riverview Rd. NE � HAN VER, MN 55341
Pho�e 763-498-8779 � Fax 763-498-8290
Joseph J. Olson--MPCA cense #810
� Juiy z2,2oos
Mike Johnson
4455 Bayside Road
Orono,Hennepin County
To whoz�it may co�cera,
�was contacCed by 7im Mohs to perform a Sepri certification on tb.e p�roperty at 4455
Bayside Road in the city of Orono. �e results of the S 'c ce�'tiScation are as follows.
Soil borings on the propexty at 4455 $ayside R . Ind�ica,te that the Septic system does
not confozm to the tbree£�t s�paration rule from the water lable.Therefore the existing
trenah system�.s iun a state a�noncom�liance to the co Chaptet 7080.
Soil boring#1 Elv:94.4 Mottled soil was 1 at Elv.-91.4
Ground at tzench#4�is at Elv-94.4 Bottom of k in trench#4 is at E1v-90.8
The ea�timg syatem is currently 6ydrnulica wert loaded but is not sa imminent
hesitt6 thr�at
If yvu have azry qu.estions pleas�ca1l.
Sincerely,
���
�Joseph J. aXson
. 07r26/2005 09: 55 763498829e RUST S PERC TESTING PAGE 03
• 1/29/02 Water/Wa�tevraCer-ISl'S�4.31
� Compliance Inspection Fo for Existing
Individuai Sewage Trea ent 5�/sbefns M�"1°�"��"�O"
co�a�o�Aqenc�►
Comp�/efiv�n of this fa,m!ulfiNs the minimal requlrements of Minn_ Stst§1 5.�5(2001)end Mlnnesvta R- QA_ 7080(1989). PlBese
refi��M k�cal o►dlnences Ibr other i►e►nents or i►�lonneflan de for lan�e ulreme►rts�bedroo►n addrtions.
S�i
Dabe of Inspeclion: �/�(05 REASON fbr I on: Pronert.v Tran�fer
p��y p�(s) n Telephone( )
p��,ep��;�; Telephone (612 j 2 -�0 92Z�
5ibe,Addre�: �Yslele d Clty: Zip Code 55359 _
Rre No./ Pa�oe! No. County: Townmhip: .
�ega�De�criPtion
Lrocsl ReguMEory�ulhorily:
Date sysbem Construrbed: 8/03/83 __ S�I�bem in oreland Mea:� no S�Isbem in Wellhead
Prob�cfion Area: yes � �ys�em servin�a MDH lia�sed fa Ilty; yes �L.Ocai Permit#(if arry) 7085
Systems built prlor G�April i, 1996 and not laat�ed in s laa�ed in Shor�and or Welihead Pro6Bction
Shoreland or Wdihead Prob�tion Ar�or Servtng a Food, Ar�eas or Servfng a Food, Beve�or Lvdgirng
Bev�erage ar Lodging Fstabl�shment Estabilshmerrt,or sysbe�r�s BufR afber
March 31 1996
�(a y�s a�asra�r/s an 1TPHS sys�►nJ (e yes arxswt�r�en I7A�Ls s1�►I
-Discha�e of sewage�the grvund�rFeoe? YES NO -Di rge of sewage�tl�e ground sUrfaoe? YES
-Disdwrge of sewage tu dralndle or svrtaoe waters? YES NO arge of sewage Lo drair�tile or surf-dce wa�ers7 YE5
-Sewage badap inbo dwelling? YES NO baclwp ir�b dwdling? YE.S N
-Sltuatlon wRh tt�e pobentlal tra Immedlatiely and - witlt tt�e pobendal m immedlabely and
adver.�eefy impect or tt�reaben publk healtl�or ImP�ct ar tttreaten public health or
� YF5 NO ? � (�
(a yes arisrr�r�s a Fa1/ir�9 sy��mJ (a yes answ�r Is a fai/i�9 sYslem)
-Less than 71A10 f�eet of vertlr�l s�aration befiNeen - tf�an THREE fa�of vettkal sepnration between
syshem bottom and saturabad soil or bedrodc? Y6 NO botLr�n and satura6ed 50U or bedrodc? �NO
-A seepage PI�oess�od,dMnel�.or leadting pit? YFS NO -A pl�►Ces�o�,drywell,or lead►in9 Pit? NO
- Is the system regulabed under a moniUoring plan or - I the system reguiaCed under a monlbonng plan or
operating permit? ('d no, go to page 2) Ye5 No ope '�9 P��?(��� 90 tp Pa9e 21 � �
If�, If)re8
-Has the required monitoring taken place? YES NO -H the requfred moniboring taken plaoe? YES NO
(!/n0,the sysfern!s►w►►-oanplYr►r91 (1� .�e 8Y��►�-�►'N�Yfi91
-The monitoring indic�te that the system meets -Th moni�ring indicabe that the system meets
performance expectationa? Y� NO rformance expecCaidons? YES PIO
(�f no, u,e system is�m�yf�) ( no, the sys�em is no►�n�php►�gl
Page 1 of 2 wq-wwists4.31
I
. 07i26/2665 09: 55 7634988290 RUST S PERC TESTING PAGE 04
p�,0perky pwdter(s) Mark�jnson �ts Add . 44bS da R�d
(P�t�e desr�de tl�e sysl�m c�mp�arae�ats):
.
What metl�ods were used eo n�ake tf�e debortninatior�s for tfie oam ianoe lnspection?(Note:Nh sYanararriproto�cn/ex,'si�
JJie fidbrving l,(st is nAt�haus�nat in s�pr�enb�/ovt�fer�r ir�tes wh axnl�i�oons are n�ry ta make a de�r»�Mad"an)
I�f� �
O Probed�Nc bot�m • Searchad for svrfaoe outict v Canducted soll borings
f:J ObServed low liquid level O P�etformed hydreulic test Depth bo limf�ng layer �4
a �camined oanst.reaords � SearChed for seeping In Deptl�Lo sysbem bottiom�$
i Examined empty(pumped)tank ❑ d�dced fbr badc up in ❑ 6camined reaords
o Probed ouCside tank for'blacic sdl" • 6coesslve ponding in soil /�ba�s O WU Umi�ng LaYer Verification
o Pres�,re/vacuum ch�dc o Home�wner�e.stimony ❑ Other
o Other o Examined for sUrging In�n
� "Black soil'above 5oU
a other
Based on tfie oompllanae criteria,the sy�n�s Is: ( one) �I falling(bo protiect gr�oundwaber) ❑ an
imminent threat to publtc health or safety(ITPHS), ❑ non-oompliaM(mont6�nng issue). ❑ oompNant(non-of the 3
pnevia,s mnditbns). is thls s�sbsm a EPA CJass V i�eciion 1? ❑ yes i no
thls document ia a: � Certific�rDe af Com Ilanoe ! N ' of Nonoom ianoe
Certlfkat�o�
1 heneby certify as a stabe pF Miru�esota lic�sed InspecOa'and/or Desgnef I QuallRed Employee Inspec�a+'andlor Qualfied Employce
D�sigr�r I ttiait I oonducted an inve�igatlon tltat dtcurdt�efy deberntined ttle pllan�e s�4js of this 5y50em and that my reCOMed
observatlons are accuratie as of thts da6e. No detemilnatlon af future hydra Ik performanoe has been nor pn be made due to
unknawn ooridltlons duNng sys0em construcdon,abuse of the sysbeari,lna ua�+e mair�enence,or future watier usage.
Inspecbors name(print) w,one: (ye3��ws-�87r.i
Lioense and/or Registration Number 810 Add�:
EmplWed bY: ' Address:
Slgnab�r+e �aLe: Z��a�os
(dey�d fiam M/n�om S�1rd�s§115.55J
An must be upgra�o�r,��aor i7s«s�dlst�ndnt�d wr[filn lan o�"reia°!�of dris noi�ae ur w�'h/n a sharier p�er�'oC If
n3quin�d by Aa�l a�lnan�re ll`the sysl�m fa!(s In provin�e�ig pvot�c�r�, �en�e.syst�.wn must be upgrad�d,
r�d� ar i�s r,cs�di�anlinu�ed within d�e Ome raqudred by ru�e vr bhe avt�0lnance If an exis�ing sysh�m is n�failinq as a�el9i�ed in
Aaw,and i�s at le�st tw�faet of G�n suN s'�oaia�ian,t1�en d�e system nat de uP9rarAe�d�poai�d,�oae+d,aw kr us�e
d�anb'nued, na�wiUis�n�ding any Aaa/orrNnan�Ghat!s moore s�t fi�fs nnt a�ly ta sysl�ms/n s�lend ar�as� r►�e,Vhe�d
Pva�aO�Ov►a2�,or d�e u,�ed in aann�c�an w�i haoid,d erer�,and �tabVls�hmen�s as atel�ned ln/aw.
i) Sibe s�ce�cft whlch tndudes tfie system loc�tion (mandat�ury). Other" oould indude: well,well sel'back to system,dwelling or
atfi�r buildings,tank(s),reserv�ed soll tr�eatrner�t area,surface waEer a soil boring loca�a�s. Include as-built drawing if avallable.
2) Soil bo�Ing logs,shawing each horiwn. Indic�abe the bexture,o�lor, morphlc features depttt bo bedrodc,s�nding waber and
whether tite materlal Is flU.
3) A flst af any and all requireqrients of tl�e lod ordfnanae that are d from tt�e staGe rt�ulrements referred�o on this form.
4) A hort�eowner svnreY of sy�em Pe�ormance.519ned by the as bdng factual.
S) MoniLoring dafa�.s apprnqia6e.
Page 2 of 2
. 07��26/2065 09:55 7634988290 RUST S PERC TESTING PAGE 05
IB .
Llcense�81 O
L,.ocatlon o�ProJect: 4�t55 Beyside Road
Borfngs made lry: Rusty Olson's Soil and Perc testing 7'��5
Classllis�tion Systsm: AASHO ; USDS-U8D8�CS l�_; Untflsd : Other
Auger ased(check two): Hand X___,or Powe� ,Flight Bucket or Probe�,�
Boring Numb� 1_SurFaoe elevs�ion___,54.4_ Mottled Soil�t 3.0_feet
0"-16" Dar1c bro�wn and brown loam(flll) H20 pre�ent ak X
18"-3Q°Dark browr�loam 10yr3/Z �
30"-38"Brown clay lo�m 10yr4J4
36",42"Rusly brawn c�a�r luam 10y�/4
. 67�26/2665 69:55 7634988290 RUST S PERC TESTING PAGE 66
, - . � Ta��.P��
July 15� 20U5
• ate�
Eimer J. Peterson Co.
5921 Dague Ave.
� Del�nc. MN 55328
;'63; 972-2420 ! (9�2) 471-815? I! .
Mark Jchnson
i455 Bayside Road '
Maple Plairi, MN. 55359
6a�ie;s� ON J OFF
T2nk CapaGity_ �
# cf '�anks:
Type of Tanks: a�
Gal�ans: zo
Pv1��holes tc Grade: YES � NO
Tanke hav� cla,rt f'loors.
�,
A10TE: This is �n��i a tank repa*t_ Th�s is noi a cflmp�i nGe ��spertiv�z fo��cir.t c� sa�e
,vr aoes �t re��ate e compi�a�ce �nspection..
License # 219
I