septic info - Laserfiche WebLink

Home Browse Search

t Parcel number: 0411723110022 System status: ®Compliant ❑Noncompliant (as determined by this form) Hydraulic Performance and Other Compliance Compliance Issue #1 of 4 Date of observation: 10/06/10 Reason for observation: Property Transfer This form expires upon next inspection or in three years,whichever occurs first: 10/06/13 Compliance questionsicriteria:(Required) Verification Method*: (Optional) (Check the appropriate box) (Check the appropriate box) Does the system discharge sewage to the ❑Yes ®No ® Searched for surface outlet ground surface? El Performed hydraulic test Does the system discharge sewage to drain ❑Yes ®No tie or surface waters? ® Searched for seeping in yard Does the system cause sewage backup ❑Yes ®No ® Checked for backup in home into dwelling or establishment? ❑ Excessive ponding in soil system/D-boxes Do other situations exist that have the ❑Yes ®No potential to immediately and adversely ❑ Homeowner testimony impact or threaten public health or safety ❑ Examined for surging in tank electrical,unsafe covers etc.)? El "Black soil"above soil dispersal system Any"yes"answer Indicates that the system/s an imminent threat to public health and safety. ❑ System requires"emergency"pumping ❑ Performed dye test Does the system pose a treat to ground ❑Yes ®No water for any conditions deemed non- protective ❑ other. as determined by the "Yes"indicates that the system is failing to protect ground water.K"yes".describe the condition noted: "No standard protocol exists. This list is not exhaustive, m sequential order,nor does it indicate which combinations are necessary to make this determination. Certification This form is to be meted and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPGA)Compliance Inspection Form for ExMng Subsurface Sewage Treatment Systems.Observations,interpretations,and conclusions must be completed by an inspector.Completed form must be submitted to the oral unit of government within 15 days. Property owner name(s): Stephen&Katherine Poley Property address: 2605 Thoroughbred Lane Orono MN 55356 Property owner's address(if different): County: Hennepin Phone: 952-404-1413 I hereby certify that I personally made the observed",interpretations,and conclusions reported on this form and that they are correct. Name: Joseph J.Olson Certification number. 1255 Business license name and number Rusty Olsoas soil and percutaton testing Lic#810 or Name of local unit government: City of Orono Signature: f Date: 10/09/10 -11 wq-wwists4-31 Compliance inspection Form for Existing SSTS 4/4/t)6