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01/20/2012 13:06 7634988290 RUSTYS PERC TES`�ING PAGL 04
<br /> Pot+c��l nLr�b+eP�; 03-117-�3-�2-t�010 System st�tus: �Compliertt ❑ Noncompliant
<br /> . -"" (as del�ertnirted by this�onn) " �!��:�°
<br /> � ;.�:
<br /> T��k 9ntegrlt�/ snd Safi�t�l Canpllar�o
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<br /> �o�����nee Issue #2 of �
<br /> De4a af observatlon: 1/20l1'1 „ R��son for observetion: Property--Trensfer _� _ �._
<br /> Thls Yorrn expires on (three yearsj: 1/20/2015 _. . „ -- - ---�
<br /> �r���ll�nce ques46onslc�tl�: (Requlred) Veriikatlon Method°": (Opuon�q
<br /> �heck the a ro riahe box (Check the app�priate box)
<br /> D�a���he systom Consist of a se�sp�ge plt`, ❑Ye: � No ❑ probed tank bottom ,
<br /> cc:��ool d II,or leachin It7 , ._._
<br /> — " ❑ Observed low liqufd level
<br /> t�o�r►y sewege tank(S)leak below their ❑Ye� �No
<br /> dssi�Jned operating.depth? _ � Exemined oonstruction records
<br /> `F ❑ Examined empty(pumped)tenk
<br /> yc��,uierrtify which se�wage .
<br /> tar�tc��8k.s. „ ;"
<br /> _ ❑ Probed outsfde t��k ft►r"black soil" ' "' !
<br /> �17�i'`�i"IM3tHR/h�CBf��i?th@ BySbsln�9'tYI�Y'i�b6 pl�Ct
<br /> �r��wstter ❑ Pressure/vecuum c9se�ck
<br /> � Other: Wete�level correct _
<br /> u �r;;���g�pi�g me�ting 7�0.�5t;U may be compliant if�Iloaved �r , .,�� ' :
<br /> irr�r�in�Vice by local p�rmittang authority.
<br /> >""�r;
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<br /> ''"No sfendard protocol exists. This list is not ezhaustivrr,ln
<br /> sequentlel Qr�er, nor does it indicete wh�h com6inations
<br /> ar�a necessary to make thls determinetion.
<br /> � � _ ,, e�sw�::
<br /> �&'����/ �hE.'C�(
<br /> 1 ' �,re�ai�y malMenanoe�hole cx�mer�damaged,crac�:�d,or e�eared to ba�ttruucturally unsound� ❑Yes' � �lo
<br /> � , , ; �
<br /> �`:� q�ler'�"�II m�irrten�nce hole a�vers replaced in a s8c:ured m�rrner(e•9-,�II sc,�+ews replaoed)? _ �Yes---.��.f�Jo«__.
<br /> �, '' '�r'��x , ,
<br /> , , .
<br /> seoondary access re�kraiM P�M(��Y P�n,seco�d caver.or saFePly netting)-hlghly r�c�rnmend�d. Yes ___. �.._
<br /> �;;srr;�lt,s�any o�Me�r.�f�oty/ha�l�;is�ue preeent7 • G . ; , :; '' :�-- _,.��;; ❑Yes' �PJo
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<br /> ��9(j1�L'!�!: : . .,w ..,.,,_ ... . � ;� ,--_ ---
<br /> wG�Y; :.' - � ..,.
<br /> ys DrnmJnent 2ir�t to publlc h�lt��rrr1 rsafetr. ' '. '
<br /> � �em ia ar�
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<br /> _ -. _ __ �l +,:�', ., ��� ir.�rn�;�s;�iui,.'�ifis�V�2�
<br /> �;���;`�'�iC��94rt , ,� . _ � � � ,,,: � .:.c.�, f�� ,,.
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<br /> TI�?:���,�-m"ss to;�completed�r►d attached to the Summ�ry Fortn of the Minn�sota Pollution Con4roi�lgi�ncj►'�(lVIPCA)Com�ll��nc�
<br /> l�•ta;���on Fortn fo�EYistlng Subaurtace 3ewage TreetmeM Sys�em�.Observatbns,irrterpr�i�t�ans,and,corldusions must b�
<br /> c�r���1�ed b��.r�lr�s�tp[�ma��+tainer,or ssrvioe p�ovider.Comphted iomn must be submitted to th�ioc�l unit of gov�nmen4 witt►in
<br /> �v�4��1;��. � � . .,..
<br /> �ro�rt�e own�r.�ame(8�;�n�Jo6�r��i3re,�lY �,;m ' "'�s � ,' ' ` _.__ _. __..--.---._-
<br /> Pra�i��ddress: �°420 Bror�rri Ftoad 5, Orono, MN 55391 M_� -_ - .__�` `.
<br /> ., • ,,,� ��,�c ;j sP i+�, +11
<br /> P�roperty oamer's address(ff dltt�r�nt): 14508 MC Gin Ftoad W. Mlnnetonka MN 55391 ,�,,,�,;,1G_
<br /> Cn�r�4�r� Hennepin w,. _._ Phone: 952-933-281�t �F�';`,e`','�,�"w',:�,,,.
<br /> I�, +'; I i
<br /> ie��by cer�ll'y t�iet I pe�sonelly made the obseroations, int�►p�etaliens, �nd aoncJus�ons ieported on t�iis fam ond tha!they b�
<br /> Gorr�cCf. . , � ,. , , . , . ,,. , ,, ^ � . ,. �'�,
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<br /> Ide7rslc: Jsse J.Ols�ori `. . K _ ._�� Certlflcatbn numbe�: 1255 ,_„_,,, _ .
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<br /> �u�isresa`ticen�e►iarrie'arid riumioeF: Ru Olson's soil end per+a�latlon�esting Lic#810 , .__ ��r
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<br /> P��rr,L of Irtcal uni gove�nment:`' City of Orono �, _ _ � ,��
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<br /> Si�it��u�' _ _ _ .._ _ ..... _. Dete_ _9120/12 --__.____ _ ._._.._. .._ .
<br /> .t;.:.. ,. �� . �:�-. �r,:-s ., .�;;�� , ,f,- .�� ..
<br /> �,rr-���,:�crc�-.�f Comnllance Insoection►�orm for Exrstina 55�'S
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