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07/18/2010 00: 03 9527586278 ADVANCED ONSITE INC PAGE 04 <br /> Parcel number: System status: ® Compliant D Noncompliant <br /> (AR determined by this form) <br /> Hydraulic Performance and Other Compliance - Compliance Inspection Form for Existing SSTS <br /> Compliance Issue #1 of 4 <br /> Date of observation: July 12,2010 Reason for observation: Property Transfer <br /> This form expires upon next inspection or in three years,whichever occurs first: July 1 2.,21113 <br /> Compliance questions/criteria: (Required) Verification Method*: (Optional) <br /> (Check the appropriate box) (Check the appropriate box) <br /> Does the system discharge sewage to the 0 Yes ® No El Searched for surface outlet <br /> yround surface? _ <br /> ❑ Performed hydraulic test <br /> Does the system discharge sewage to drain ❑Yes El No <br /> tile or surface waters? _ Searched for seeping in yard <br /> Does the system cause sewage backup ❑Yes ® No ❑ Checked for backup in home <br /> into dwelling or establishment? LI Excessive ponding in soil systemlD-boxes <br /> Do other situations exist that have the 0 Yes (3 No ❑ Homeowner testimony <br /> potential to immediately and adversely <br /> impact or threaten public health or safety ❑ Examined for surging in tank <br /> (electrical, unsafe covers,etc.)? _-- ❑ "Slack soil"above soil dispersal system <br /> Any"yes"answer indicates that the system is an imminent <br /> threat to public health and safety. ❑ System requires"emergency"pumping <br /> LI Performed dye test <br /> Does the system pose a threat to ground ❑Yes ® No Other; Estate Executor Testimony <br /> water for any conditions deemed non- - <br /> _protective as determined by the inspector? <br /> "Yes"indicates that the system is failing to protect <br /> ground water.If"yes", describe the condition noted: <br /> No standard protocol exists. This list is not exhaustive, <br /> in sequential order, 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 Form for Existing Subsurface Sewage Treatment Systems.Observations, interpretations, and conclusions must be <br /> completed by an inspector. Completed form must be submitted to the local unit of government within 15 days. <br /> Property owner name(s): Estate of Diana Gross (Attn: Rich Gross) <br /> Property address: 55 Wear Lane North Orono, MN.55356 <br /> Property owner's address(if different): (Attn:Rich) 721 Bridal Path Trail Hamel, MN. 55340 <br /> County: Hennepin Property owner phone: Rich: (612)865-8598 <br /> I hereby certify that I personally made the or• -ovations, interpretations, and conclusions reported on this form and that they am <br /> correct. <br /> 1 Name: Thomas Klanchnik Certification number: R 6046 <br /> Business license name and n • be' Advanced OnSite, Inc. L 2656 or <br /> Name of local unit of go 09A(/ierr <br /> Signature: Al Date: July 17,2010 <br /> www.pca.state.mn.us • 651-296-6300 • 800.657.3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats <br />