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08/20/2010 15:42 7634988290 RUSTYS PERC TESTING PAGE 02 r Minnesota Pollution 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: 0411723210010 For Local Tracking Purposes: System status: ® Compliant ❑ Noncompliant (based on all compliance requirements) Summary Form Property Information Property owner name(s): Michael Francis Property address: 2995 Watertown Road, Orono,MN 56366 Property owner's address(If dltferent): County: Hennepin Property owner phone: Permitting authority: _Ci!y of Orono Date system constructed: _6/11/01 Reason for Inspection: Property Transfer System Description ---- Approximately 2-1300 gallon septic tanks, 1-1300 gallon lift station and Approximately 7500 square Brief system description: feet of mound rockbed. Local permit number: _ Number of bedrooms: B 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?❑ Yes 0 No of Heath(MDH) licensed facility? ❑Yes ® No Compliance Status(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 until (3 years from date of report): 8/16/2010 ❑ Notice of Noncompliance-For Nonoompliant systems: The reason for noncompliance is: his noncompliant system Is classified as(check one below). ❑ Imminent threat to public health&safety ❑ Failing to protect ground water ❑ Not in compliance with operating permit Certification (Completed form must be submitted to the local unit of govemment within 15 days.) I hereby certify that all the necessary informa6on has been gathered to determine the compliance status of this system. No determinahon 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 x Certification number: 1255 _ Business license name and number Rusty Olson's soil and perculation testing Lic#810 _ _ or Name of local unit of government: City of Orono Signature Date: 8/20/10 Required Attachments Inspector Complete:This Inspection Report is pages long. Check compliance forms attached: ®Hydraulic Performance ❑Tank Integrity ®Soil Separation ❑Operating Permit Form(if applicable) ❑System drawing/As-built drawing ❑An assessment of any local raqulrements that are different from what is required on this form ®Soil Boring Loge 0 Abandonment form Cif approprtaw) ❑Other information(fist): Upgrade RegUlrememB(derived ftn"Minn. Star.§995.55)An immment threat to public health and s&MW(ITPH$)must be upgraded,replaced,or ib sae dlScartt/nued within ten months of receipf of this notice or within a shower pwloe Jf mqubed by Aoml ordinance.ff the systam Is railing to protect ground water.Me system must Of upgraded replaced,or Ire use discontinued wphin the time requlmd by act/ordinance.If an existing systtm is not failing as defined in few,and has of least two feet of design soli separation,then Me system need not be upgraded,repaired,replaced,or its use discontinued,notwithstanding any local ordinance that Is more sma This provision does nor apply to systems in shomiand areas,wellheed Protection Areas,or those used In connection with food, beverage,and lodging esteolishmonta as der►ned in law. wq-wwlsts4-31 Compliance Inspection Form for Existing SSTS A/.rrno