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08/20/2010 15:42 7634988290 RUSTYS PERC TESTING PAGE 03 <br /> Parcel number 0411723210010 System status: ®Compliant ❑Noncompliant <br /> (as determined by tills lam) <br /> l"ll'sulic PerFor1111UMM and Other Compliance <br /> COMPHance Issue#1 of 4 <br /> Date of observation: 8/16110 Reason for observation: _Pmpft Transfer <br /> This foam expires upon next inspection or in three yam,whichever ooaxs tir8t 8/16113 <br /> Compliance qundons/cliteda: (Required) VeMdcation Method': (Optional) <br /> Check the appippriate.bout (Check the appropriate bac) <br /> Does the system discharge sewage to the ❑Yes O No surface? ® Searched for surface outlet <br /> round <br /> Does the system discharge sewage to drain ❑Yek ®No ❑ Performed hydraulic test <br /> We or surface waters? ® Searched for seeping in yard <br /> Does the system cause sewage backup ❑Yes ®No ® Checked for backup in home <br /> Into OL*Nna or establishment? ❑ Excessive ponding in soil system/D-boxes <br /> Do other situations wrist that have the ❑Yes ONO Q Homeowner testimony <br /> potential to Immediately and adversely <br /> Impact or threaten public health or safety ❑ Examined for surging in tank <br /> electrical unsefe covers,oft.? <br /> Any"yes"ensnarer Mdrea w that the system/s an imminent ❑ 'Bled loll'shove soil dispersal System <br /> tlrrawttoputift hsalM andsati3ty. ❑ System requires'emergenc "pumping <br /> ❑ Performed dye test <br /> Does the system pose a threat to grand ❑Yes ®No 00W. <br /> protective <br /> water for any conditions deemed non- <br /> ' as determined by the <br /> Yes"Ind that the system Rs to protect <br /> ground waster.If wyes",deacdbo the condltlon noted. <br /> 'Alb standard pn)kxd exists. This list is not exhaustive, <br /> in sequential cider,nor does it indicate which <br /> combinations are necessary to make this determination. <br /> Certification <br /> This form Is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compliance <br /> Inspection Farm for Erdsting Subsurface Sewage Treatment Systems.Observations,interpretations,and conclusions must be <br /> completed by an inspector.Complatad form must be submWed to the local Limit of government within 15 days. <br /> Property owner name(s): Michael Francis <br /> Property address. 2W5 Watertown Road,Orono,MN 55356 <br /> Property uwners address(If diifesnt): <br /> County: Hennepin Phone: <br /> I hereby cer6Tjr that I personally made the obsemb rig,ir►terpretatkuns,and conclusions reported on this ftm and that they are <br /> correct. <br /> Name: Joseph J.Olson Certi(ication number: 1255 <br /> Business license name and number; Rushy Olson's soil and peryuMon mina Lic S 810 or <br /> Name of local unit of government: Cites of Orono <br /> Signature: Date: 8/20/10 <br /> wq-wwbts+31 Compliance inspection Form for Existing 5ST5 <br />