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12108l2010 09: 57 ro34988290 RUSTVS PERC TESTING PAG� 02 / <br /> --..... ...._...__... �� <br /> , � <br /> �w�nnesota Pollution Compliance Insp�ction Forrr�n <br /> Control Agency <br /> 520 Lafayette Road Nor�h �s�^s ���� ��e T��e�t ��s (�TS) <br /> 5c Paul,MN 55155-a194 IliStrUCtiOnS ol1 pA�e 7 <br /> Parcel number. For Loc�l Tr�dcing Purposes: <br /> System status: �Compllarrt ❑ Nonoompliant <br /> (bass+��d on ell canpllence requlrements) <br /> �ummary Por�n <br /> Property Information <br /> Property o�wner neme(s)- M�ttt&Cartie VanSboten <br /> property ad�areas; 364Q Jeoobs Mill Road,Orono MN 55356 <br /> Ftop�xty o+Nners atldress(if diAenent): <br /> �y�h: H��� Property owner Phone: 612-309� Pertnitting aud�iiY: C af Orono <br /> D�te system oonstruct�ed: 10101/04 Reeson for inspectfan- Pro Transfer <br /> System Oescriptivn <br /> ApProbmately 2-1300 gsl{on septic t�nlcs, 1-1300 galton liR station and Appro�dmetely 630 sque�re <br /> Brief syetem d�aiplbn: f�et of mound rodcb�d as � r�cords. <br /> Locel permit number: i'06021 Numbe�of bedrooms: 5 Design flaw rete: �83 _ <br /> Is d�e system: <br /> In S�ore�end a�s? ❑Y�8 �Mo In WeNheaQ Profectiori Aoea? ❑Yes � No <br /> An U.S.Ernrironment�l Protec�n System sendn9 a M+nrre�o�ta DePaAment <br /> A9�x'y(�PA)Cless V Ir�ection WeN?O Yes � No of He�th @ADH)tio�sed facility? ❑Yes �iVo-- - <br /> C011r1plienC� Stetus(Ba��d on stete re4u�rements-additiona��ocel re9uiremerrta m�y also apply.) <br /> Based on the information g�tltered and reported on atteched Tnrms,tfie compliance status of this syskem is(check one): <br /> �CertJflcete of Compllanoe–valid ur�til(3 yeaos from d8te of�epor�: 1?J3/Z010 <br /> �Notice of Nonoomplianc;e-For Plonc�rnpliant systems: <br /> The reason for nonownptia�noe 16: _ —� <br /> Thls no�rc�ompli�rrt sysberm!a cla�lfled as(chsck one bslaw): w�ter Q Nat In compllan�e with operating pertnit <br /> ❑ Imminent threat to publfc heafth�safety ❑Fa�lfng bo p�oted gmund i <br /> CertifiCatl�t(Completed inm�must b�submitted to ihe Ioca1 unit of govemrnent withln 15 d8ys-) <br /> 1 hereby ce�tif�thet all the neaessery informeUon has been gathered to detem�lr►e the cnmPl�ence status of thfs system.!Vo <br /> rl�t�m�ddnetiora af future system pe►1bnr�eru:e hes been nor cen b�mode due to uMarrawn conditi�ons during syste►n const�er►, <br /> ppssibl�abuse of tl�e sy�stem.inedequale meinf+anancs, or future water usa�a- <br /> Name: Joae h J.Olson CerdHca6o+�number: 125� <br /> Bu�i�s Ik;ense name ancf na�mber R l�lson's sofl and lation Lic#810 0� <br /> tUeme of local unit of Ao�em�merrt: C' oF Orono _ <br /> Signatune:� -�- DaUe: 12J08/9 0 <br /> '��+uired Attachment� �nspedor Complet�e:Thi� Inspection Repo�t le '_�^Pa9es long. <br /> .._�ee b�ms�t�ehad: �Hydrautic Peafonnsnos �TaMc Inbap�illl �Soil Separatlon ❑OperaGn9 PermM Form(if <br /> n dca+ring/Asdwift drawinH ❑M�of any rowl requUeme�t�at are diRerent fiom what fs re4uired on this <br /> ,.� ❑Aba�dorKnent fonm(M eppropriarle) �Otf�er b�lortt�atbn(list): <br /> romer�(de►fred from M/nn-Siat§115.55)M arvnrna►r th,eet ro puanc nsa�t�a�,e asneq�pTaHS)muar ce u�raaw,recreced,a�r <br /> M�fhln�n mondrs W�pf of MJa naUce w wit�in a aAat�D���rsqaY�d bY local aWrtence.K tl�s sysfem i�/aiJNp fo P�9�� <br /> ws[Oe upPr�tl�d,hplitod.or�a uf1 d�Bcontlnued�YfCIM fha Lme rsquhs0 bY��oNfAMCB.If en eXlSCA9&y8fa►n is I!W/elllnp as 0lfilOd M <br /> �h.o la�t ot aealvn�1 sepsranon,then me sysram naed rrot es dpy►sGad.iapei+sd,r�pscad.or;ba uae draountinueQ,aohn'thatanelnp vrY <br /> �t la mao ebkt 71iia provl�/on daea nnt eppry to ayafema in ahou�lend e►�a W�YMed P�vler�on A�ea,or Hraas used�connetUon wlJh lood <br /> fpin8 a�eblislrRl�nlB ea delPrred br l�w, <br /> r.w.��ltnnr.o lmnection Form for Euistln�SSTS <br />