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08/20/2010 15:42 7634988290 RUSTYS PERC TESTING PAGE 04 <br /> ,uv arc-torr P.G <br /> Percef number: SYetam statae <br /> ❑Compliant ❑Noncompiiart <br /> (aa deremdrled by this Ibrm <br /> Ts"k 1"ft and Safi Comphails" -Comp"noe kWP0Cd0n Fvlln !bf Existing SSTS <br /> Compliance Issue #2 of 4 <br /> Date of observation: Resson for obmwvsoon: Request from Eric Myhran-Resitor <br /> This form expires on(three years): 811?/10 <br /> Compllawvequeistions/ClRN 4: (Required) lhrllication AAsAfvd":(Optionral) <br /> `ak Ills <br /> Does the (Check the sppra Pride box) <br /> syacem cotterel of a seepage plY, El Yes {�No <br /> teas ool d I,or Iescn ❑ Probed tank bafom <br /> Do any sew W tanks)leak below their ❑Yes No 13 Observed iNonr li�r(0!ever <br /> assigned oWdng dt th? ❑ Examined contitruccon reconea <br /> If yes,identify which Examined amplyy(pumped)tank <br /> sewage tank leaks <br /> AiW"yea4 enwWMXpgW"fbWow graham ii fmring so P+'�f ❑ Probed mods tank for•black sal' <br /> ground**far. ❑ Pressuretva mum check <br /> Seepegs pib Ift UhIll 7080.2550 may be eompik M If allowed ❑ Other <br /> in ordinance by local permitting eutho*. <br /> No alsnndord p►*cW sa sts. This liai is dot exbar:avw'in <br /> mwerba wdsr.nor db@v iYk iv@w whir~h wmbm&6W s <br /> are naceasary to mate dhls daleimkofion. <br /> Safety Check <br /> 1. Are mirirOfmce able covers dalnetged,craciaea,or appeared to be madly unsound? ❑Yes' ®No <br /> 2, Were maintenance hole covers replaced in e segued manner(s.g.,screws replamed)? ®You []No- <br /> 3. Was ssoonttary access restrdnt present(eallegr pan,second cover,or salbgt rending)-highly recommended. ❑YesA' No <br /> 4. Are other saft- wi>e t issue pressat? Q Yes' ■Na <br /> %yallaw is an bnAinewir dt►so p publk health aw sanely. <br /> Certification <br /> Ttla form is to tie completed end attached to the Summery Form clans Minnesota POHlution Control Agency's(MPGA)Conolance <br /> Inspedton Form for Existing Subsurface Sewage Treabuset8ysbems.Observations,interpretations,and conclusions must be <br /> completed by on inspector, ma intsiner,or seriice provider.Completed form must be subri ftted m the local unit oh govemment within <br /> 15 days. <br /> Property owner narrWsh mel Fronds <br /> Property address: 2995 Watertown Ind. Orono, MN 5585iB <br /> Property owners address(If dllamrp: <br /> Counitr. Hennepin Property owner phone; Erlo Myhren 1112$10-37415 <br /> I h&raby certify that I permnefly trade the absenvoWns,lnterpnetat(ons,and oombbrsions rapaled an flus farm and that they ata <br /> correct. <br /> Mame: James BrasgelMsrn Certfficallon number. <br /> Busing"license name and number Domer J. Peterson Co. LicarrAW219 or-� <br /> Nam:7re- <br /> www-PO4tift-MUS <br /> Sign - 661-296.6300 . 6"7-3564 TTY 651-2112-532'2 or f M4S7--3864 . Available in ammathve formats <br /> w q-wwlsrs4-J1 s 4124!09 <br /> Phe 3 of 8 <br />