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04/18/2009 14:30 7634988290 RUSTYS PERC TESTING PAGE 03 <br /> Parcel number: 33-118-23-41-0007 System status: ® Compliant ❑ Noncompliant <br /> (as determined by this form) <br /> Hydraulic Performance and Other Compliance <br /> Compliance issue #1 of 4 <br /> Date of observation: 4/09/09 Reason for observation; Property Transfer <br /> This form expires upon next inspection or in three years,whichever occurs first: 4/09/12 <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 ❑Yes ® No ® Searched for surface outlet <br /> round surface? <br /> Does the system discharge sewage to drain ❑Yes ® No ❑ Performed hydraulic test <br /> tile or surface waters? [4 Searched for seeping in yard <br /> Does the system cause sewage backup 0 Yes E No ® Checked for backup in home <br /> into dwelling or establishment? <br /> 0 Excessive ponding in soil system/D-boxes <br /> Do other situations exist that have the 0 Yes ® No <br /> potential to immediately and adversely Homeowner testimony <br /> impact or threaten public health or safety ❑ Examined for surging in tank <br /> (electrical,unsafe covers.etc. ? <br /> ❑ "Black soil"above soil dispersal system <br /> Any"yes"answer Indicates that the system Is an imminent <br /> threat to public health end safety. ❑ System requires'emergency pumping <br /> ❑ Performed dye test <br /> Does the system pose a threat to ground 0 Yes ® No <br /> water for any conditions deemed non- ❑ Other: _ <br /> protective as determined by the inspector? <br /> "Yes"Indicates that the system Is foiling 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 condusions 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): Foreclose <br /> Property address: 2550 Woodhaven Drive <br /> Property owner's address(if different): <br /> County: Henna in Phone: <br /> I hereby certify that I personally made the observations, interpretations, and conclusions reported on this form and that they are <br /> correct. <br /> Name: Jos ph J.Olson Certification number; 1255 <br /> Business license name and number: Rus Olson's soil and rculation testin Lic#810 or <br /> Name of local u of government: City of Orono _ <br /> Signature Date: 4/09/09 <br /> • <br /> wq-wwisrs4-31 <br /> Cemnlinnry InenorHnn Fnrm f,,. cc-rc <br />