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� ✓ Minnesota Poilution Compliance Inspection Form Control Agency 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems (SSTS) St.Paul,MN 55155-4194 Instructions on page 7 Parcel number: 0411723340008 For Local Tracking Purposes: System status: � Compliant ❑ Noncompliant (based on all compliance►equirements) Summary Form Property Information Property owner name(s): Chistopher Smith Property address: 2943 Farview Lane,Orono,MN 55356 Property ownePs address(if different): County: Hennepin Property owner phone: 952-404-3337 Permitting authority: City of Orono Date system constructed: 9/08/03 Reason for inspection: Property Transfer System Description Approximately 2-1300 gallon septic tanks, 1-1300 gallon lift station and Approximately 630 square Brief system description: feet of mound rodcbed as per city records. Local permit number: P06672 Number of bedrooms: 5 Design flow rate: .83 Is the system: In Shoreland area? �Yes ❑ No In Wellhead Protection Area? ❑Yes � No An U.S. Environmental Protection System serving a Minnesota Department Agency(EPA)Class V Injection Well?0 Yes � No of Heath(MDH)licensed facility? ❑Yes � No COI'T1P�1dnC@ $t8tU5(Based on state requirements—additional local requirements may also apply.) Based on the information gathered and reported on attached forms,the compliance status of this system is(check one): �Certificate of Compliance—valid u�til(3 years from date of report): 10/11/2010 ❑Notice of Noncompliance-For Noncompliant systems: The reason for noncompliance is: This noncompliant system is classified as(check one below): ❑ Imminent threat to public health&safery ❑ Failing to protect ground water ❑ Not in compliance with operating permit C@rt1flCdtlOn (Completed form must be submitted to the local unit of government within 15 days.) 1 hereby certify that all the necessary informafion has been gathered fo determine the compliance status of this system. No determination of future system performance has been nor can be made due to unknown conditions during system construction, possible abuse of the system, inadequate maintenance, or future water usage. Name: Joseph J.Olson Certification number: 1255 Business license name and number: Rusty Olson's soil and perculation testing Lic#810 or Name of local unit overnment: Ciry of Orono Signature: Date: 10/11/10 Require Attachments �nspectorComplete:This Inspection Report is (� pages long. Check compliance fortns attached: �Hydraulic Performance �Tank Integrity �Soil Separation ❑Operating Permit Fortn(if applipble) �System drawing/As�uift drawing ❑An assessment of any local requirements that are diffierent from what is required on this form �Soil Boring Logs ❑Abandonment form(if appropriate) ❑Other infonnation(list): Upgr'dde Requirements(derived from Minn_Stat.§115.55)M imminent threat to public heafth and satety(ITPHS)must be upgraded,repJaced,or its use discon5nued within ten monUrs of�aei�of this notice or within a shorter period if required by loca/ordinance.If the system is failing to protect ground water,the system must be upgraded,rep/aced.or its use discontinued within the time required by loca/ordinance.If an existing system is not failing as defined in law,and has at least hvo feet of design soil separation,then the system need not be upg2ded,repaired,replaced,or its use disContinued,nohvithstanding any local ordinance that is more shict. This provision dces not appty to systems in shore/and areas,Wellhead Protection Areas,or thase used rn connection with food, beverage,and lodging establishments as defined in law. wq-wwists4-31 Compliance Inspection Form for Existing SSTS 4/4/08