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06127/2609 12:39 7634988299 RUSTYS PERC TESTING PAGE 03 <br /> Parcel number: System statu�: � Complient ❑ Noncompliant <br /> (as defe�rnirted by this Iorm) <br /> Hydraulic Porfor�nance and Oth�r Gomplisnce <br /> Compliance Issue #�1 of 4 <br /> Date of observation: �/26J09 Reason for observetion: P Tran�fer <br /> This form expires upan neact Inspection or in three years,whichever occurs�tst: 6/26/72 <br /> Compllance questionslcrlteMa: (ReQuired) VerHlcatlon Method•: (Option�l) <br /> cned�me a � ►�are�►x �cnecn me a�rop�ete box� <br /> Doea the system discharge sewage to the ❑Yes � No � gearched for surtace outiet <br /> round surFeoe? <br /> ❑ Perform�d hydraulic test <br /> Does tt�e system discharge sewege to drain ❑Yes � No <br /> tfle or surteoe waters? � Searched for seepinp in yard <br /> Does the eystem cause sewage badcup ❑Yes �No � Chedced for backup in home <br /> into dwellln or estaWishmen� ❑ Exce�sive ponding in soll system/D-boxes <br /> Da other sltuetions axist that have the ❑Yes � No � Homeowner testimn�y <br /> potentlal to immedietely and adversely <br /> impact or threaten public health o�safety ❑ Examined for surging in tenk <br /> electricel,unsafe cove►s etc, ? <br /> --- ❑ "Bladc soil"above sal dispersal system <br /> Any"yss"anewar lndkahs tlwt�s sysbm!s an Imminent <br /> thieat to publfc hea/M ertd aal6ty. ❑ System r�equires"emergency° pumpine <br /> -• ❑ Pertormed dye test <br /> Does the system pose a thrseat to ground ❑Yea � No � p�er: <br /> water for any mndltione de�ned nan- ' <br /> robedive as detertnined b the ins ,,, <br /> "Yaa"lndicates that tha aysvwn ia failinq to prot�ct <br /> ground wstoe,K"y�';dascrlbe tlre condltlon notod: <br /> 'No stenderd protocd exists. Thls list is not exhausNve, <br /> in sequentiel order,nor does it indicafe which <br /> combinetions aie necessery to mak�this determinetion. <br /> Certification <br /> Thls form is tn be completed and a�ed to the Summary Form of the Minnesots Pollu6on CoMrol AOency's(MPCA)Compllance <br /> Inspection Fomn for Exlstln�8ubsuAace Se�ge TraabneM Syst�ms.Observatfons,tnterpretations,and c�ondusions must be <br /> completed by an inspedor.Compleoted tu�n must be submitted to the local unit of govemment within 15 days. <br /> Property ovmer name(sp Catherine Johnston <br /> Property address: 840 Brown Rvad 5 Orono,MN 55391 __ <br /> Property ovmer6 edCr�eBS(ff different): <br /> County: Henne in Pho�e: 612-770-1799 _ <br /> 1 hereby ceMry thet I peisonally made the observe6on�,interpretallons, end oo►►c�us�o.►s repo�t�d o►►r��s�om�end mer rney a� <br /> correct. <br /> Name: Joseph J.Olson Certficetfon number: 1265 <br /> Busineas license name snd numbar: Rusty Olson'��oil end perculetion teed� Lic#910 0� <br /> Name o�f locel unH govemmerrt- CitY of Orono , <br /> Slgneture: _ Date: 6/Z7N09 _ <br /> wq-wwfstsd-31 Compliance Inspectfon Form for Exist/ng SSTS <br />