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11/14/2011 14:23 952-955-5071 BURNS EXCAVATING PAGE 02 <br /> N E 90 T A Minnesota Department of Health <br /> Well Management Section <br /> P.O. Box 64975,St.Paul,Minnesota 55164-0975 <br /> 651/201-4600 or 800/383-9808 <br /> Certification of Buried Sewer Construction and Testing <br /> This form must be completed axed submitted to the Minnesota Department of Heals WH)for installation l located <br /> d a <br /> buried sewer located 20 to 50 feet from a water-supply well, or the installation of PP Y <br /> 20 to 50 feet from a buried sewer.NOTE: A 50-foot minimum separation must be maintained between a <br /> water-supply well and a buried collector or municipal sewer,an unapproved sewer, or a buried sewer serving a <br /> facility handling infectious or pathological waste. <br /> Owner of 1?ropaV Wham Sewer is Located(please print) <br /> PIC444[ZeJ <br /> Street Address,City.7.iP for PropertY Whore Sewer's Located <br /> Zq$S' !A- 'O Lv1Ll by�cj o p-bx1b, M AJ. 5 57r <br /> County Name 'tbwnship No. Range No. Section No. Practioa <br /> t�4 �4 1/4 <br /> t,j�i 6 fu <br /> (mtr✓ddlyyyy) person(s)Preswt to witness Testing <br /> Well Information <br /> Provide Minnesota Well and Boring Number(s) or,if unavailable, <br /> Ovide the followinginformation for each well located within 50 feet of the buried sewer, well Address <br /> Well well Year of Well Contractor <br /> Well No./Aescridon ]Depth Diatacter Construction Co an Nome <br /> if diffemnt from above <br /> Variance Information <br /> Was a variance issued by the MDH for this sewer or well installation? ❑Yes Jallo <br /> If yes,please provide the variance tracking number: TN <br /> Sewer Materials <br /> ❑ ABS (ASTM D2661) [] ABS (ASTM D2751) ❑ ABS (ASTM F628) <br /> gPVC(ASTM D2665) ❑ PVC(ASTM D3034) PVC(ASTM F789) <br /> PVC(ASTM F891.) ❑ Cast Iron- <br /> Test Methods (check one) <br /> Air Test(5 psi constant pressure for 15 minutes). <br /> Manometer Test(1-inch water column). <br /> ❑ Hydrostatic Test(for plastic pipe only). <br /> The portion of the buried sewer system tested is described as follows(please specify each segment of sewer <br /> pipe which was tested). ,rip <br /> Please draw a diagram of the sewer system on back and note the locations of any wells and the portions of <br /> the sewer system that were pressure tested. <br />