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09/16/2616 10: 16 7634988296 RUSTYS PERC TESTING PAGE 03 <br /> Paroel number. 0511723120021 � System status: �CompliaM ❑Noricompliant <br /> (as determined by tltafs fom�) <br /> Hydraulic Peirforn�ancv and Othor Compllance <br /> Compliance Issue #1 of 4 <br /> Oate of obaervation: 2/15/10 Reasvn for oDsenratlon: Property 7ransfer <br /> Thig form expires upon naxt inspection or in ttu�ae years,whichever occurs first: 2/15/13 _ <br /> Cvmpliance questiorfs/Criberi�: (Requiroed) VerfRCadae Metl�od': (Optianal) <br /> Check the a riate box (Check the app►opriet�a box) <br /> Does the system dlscherge sewage to the ❑Yes � No � Searched for surface outlet <br /> round surfeae? <br /> Ooes the s�rstem dis�erge sewage m drain ❑Yes � No � P�"��draulic t�est <br /> tile or surface waters? � Seerched fo�seeping in yard <br /> Does the system cause sewege backup ❑Yea � Na � Chedcod for badcup in home <br /> into dwellin or establlahment7 <br /> ❑ 6coesBive ponding in soll systeml0-boxes <br /> Do othe�situa�vns eudst tfiat have the ❑Yes �No [] Homeowner testimony <br /> potentiat io immediately end edversely <br /> impact or threaten public heal�or safety ❑ Exsmined for surging in tank <br /> elgCt�iCal unsafe covers etc. ? <br /> Any"yea"an�aw�er Indlcebs Uwt tIw ay►atem(s an ImrMnmrt ❑ "81adc so��"above soil dispe�sal system <br /> ����pq���ry���/�y, ❑ S�rstem requlres'emergenc.y"pumping <br /> ❑ PerfioRned dy�e test <br /> Doea the sys6em po�e a threet to�round ❑Yes �No ❑ Ottier: <br /> water for any aondi6o►►s deenred rwn- <br /> �rotecdve 8s de4ennlned the' ,,,,� . <br /> "Yes"ind�taCY�s ohat tlw�ys�n ia falliny to pro69Ct _ <br /> ground wet�r.If"ysa",describe drs�ondltbn noted: <br /> 'No standercl proi9ocoJ eixists- Thls//st!a not exhaustive, <br /> in s+�quendal oNer, nor dbes it indicete which <br /> combinatior►s�ie ne�essary to meke this determinstfon. <br /> Certification <br /> This form is to be oomple�ted and aKach�d to the Summary Fom�of the Minnesota Pollution Corrtrol Agencys(MPCA)Compllamce <br /> Inspection Form for Exl�tir�Subsurigca Sewage Treatrnent Systems.Obs�netivns,ir�berpretations,and candusions must be <br /> completed by an inspector.Completed fvm►must be suMrdlb�d b the Ixa)unit of govemme�withfn 15 days. <br /> P�operty awner name(s): Cartton Hagberg _ .,.__ <br /> Prvperty address: 3485 Chris6n�Drlve,Orono, Mld 55359 � _ <br /> Property ovmeNs address(if d9tPerenq: <br /> County: Henne In _ „ ,_,�_ Phone: 612-36fl-8118 <br /> 1 hereby caertify thet 1 persana0y made the observetlons,int�rprel�tions.and oonduaiars repOR+ed on this larm and that they ar�r <br /> norreCt- <br /> Name: Joseph J.Olsqn Certiflcation number: 1255 <br /> Business license name and number: Ru�y Olson's soil and�„er+culetion teeting Lic#810 or <br /> Name of local unit govemment: C�d ,' ,of Orono , <br /> SignaUure: _ Date: 8l15/10.,.„'.__- - <br /> r„4_�saq_3� Compliance In��,pection Fvrm�nr Exlsting SSTS <br />