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10/29/2010 11: 29 7634988290 RUSTV'S PERC TESTING PAGE 03 5 Parcel number: , 26-118-23-41-0009 System status: ® Compliant ❑Noncompliant (as determined by this loan) Hydraulic Performance and Other Compliance Compliance Issue #1 of 4 Date of observation: 10/18/10 Reason for observation: point of sale _ This form expires upon next inspection or In three years,whichever occurs first: 10/18/13 Compliance questionsicriterla: (Required) Verification Method': (Optional) LCheck the ep vale box) (Check the appropriate box) Does the system discharge sewage to the ❑Yes ®No round surface? ® Searched for surface outlet Does the system discharge ❑ Performed hydraulic test y rge sewage to drain ❑Yes ®No the or surface waters? ED Searched for seeping in yard Does the system cause sewage backup ❑Yes ® No ® Checked for backup in home into dwelling or establishment? -_ El Excessive ponding in soil system/D-boxes Do other situations exist that have the ❑Yes 1Z No potential to immediately and adversely ❑ Homeowner testimony impact or threaten public health or safety ❑ Examined for surging In tank electrical, unsafe covers, etc.)? _ Any"yes"answer indicates that the system/s an Imminent [3 "Bleck soli'above sail dispersal system threat to public health and safety. ❑ System requires'emergency"pumping ❑ Performed dye test Does the system pose a threat to ground ❑Yes ® No water for any conditions deemed non- ❑ Other _P_rotedive es determined b the Inspector? "Yes"Indlcetas that the system is falling to protect ground water.If-yes-, deacrlbe the condidan noted: No standard protocol exists. This list is not exhaustive, - in sequential order, nor does it indicate which combinations are necessary to make this determination. Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compliance Inspection Form for Existing Subsurface Sewage Treatment Systems. Observations, interpretations, and conclusions must be completed by an inspector. Completed form must be submitted to the local unit of government within 15 days. Property owner name(s): Richard Seitz Property address: 1185 W j!!gmere Road Property owner's address(K dlfterent): County: Hennepin Phone: 952-545-1005 I hereby certify that I personally made the observations, interpretations, and conclusions reported on this forrn and that they are correct. Name: Joseph J.Olson Certification number: 1255 Business license name and number: Rusty Olson's soil and perculatlon testing 810 or . . Name of local unit of government: Signature: — Date: 1023/10 wq-wwlsrs4-31 Compliance inspection Form for Existing SSTS 414108