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s ParcN number. 0419723310015 5ystem status: �ComplianL ❑NoncompGant (as defem�ined by ihis fiim) . -•- f �----.�. . .._...._.... . .�_. ....... ._ _. . ,....... ... . .. . ...�..... ... t � <. .. -- - ., . . . ._.. .. .. _ liydraulic Performance and Other Comptiance Comptiance issue#1 of 4 Date of observation: 7/13/11 Reason fo�observation: Property Trans�fer This form expires upan next inspection or in three years,whichever oc.curs first 7h312014 Compliance questionslcriteria:(Required) VerficaYron Method":(Opti�ral) Chedc the a ro riafe box (�q�;ph�appmpriate box) Does the system discharge sewage to the ❑Yes �No round surface? � Searched fo�surface outlet Does the system d'�scNarge sewage to drain ❑Ycs �No � Pe�fomied hydraufic test tile or surface waters? � Searched for seeping in yard Does the system cause sewage backup ❑Yes �No � Chedced for badcup in home into dweliin or estabiishment? ❑ ��e ponding in soil system/D-boxes Do other situations e�dst that have the ❑Yes �No potential to immediately and adversely ❑ Homeowner testimary impact or threaten public heaith or safety ❑ Examined for surging in tank etedrical,unsafe covers,etc.? Any"yes"answer indicafes that the system is arr imminent ❑ "Bladc sfl�'above sod d�spetsal system th,�eat to public freakh and safety. ❑ System requires`emergencyr pumping ❑ Performed dye test Does the sysEem pose a threat to groimd ❑Yes �No � ��, water for any conditions deemed non- rotective as determined b She ins "Yes"indieates that the sysNem is failing to protect ground water,lf`�res",describe ft►e condihion notad: 'No sfandeN prafoco/exists.Thi,s fist is not exhaustive, in sequeMial ortier,rwr does it indicate which combinations are neoessary to make(rus dei�ermanation. Certification This fomi is to be r,ompleted and attached to U�e Summary Form of the Minnesota Poilution Coritrol qg�s(MPCA)Compiiance Inspection Form for Existing Subsurface Sewage TreaLnerrt Systems.Observatior�s,i�retations,and conGusions must be complebed by an inspector.Comp�form must be submitted to the Iocat unit of govemmerrt within 15 days. Property owner name(s): C[audi Wiseberg Property address: 2980 Sussex Road Orono,MN 55356 Property owne�s address(�f differert): Courriy: Hennepin Phone: 612-860-8560 1 hereby certify that t personally made U�e observations,fnterpretabons, and conclusions reported orr this fom►and that U�ey are corr�t Name: Joseph J.Olson Cer6fication number. 1255 Business license name and number: Rusty Olson's soil and perculation testing Lic#890 or Name of local unit . ove �--Eily�af Orono Signature: _ . Date: 7115J11 wq-wwists4-31 Compliance lnspection Form for Fxisting SSTS 4/4/OB