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05/25/2010 16:40 7634988290 RUSTYS PERC TESTING PAGE 03 <br /> Parcel number: 3311823430017 System st�tus: � Compliant ❑ Noncompliant <br /> (es determined by this form) <br /> Hydraulic Perfonr�anas and Other Compllance <br /> Compliance Issue #1 of 4 <br /> Dete of observation: 5119/10 _ Reason for observation: Prowperiy Trenefer __ �, <br /> Thls form expires upon next inspection or In three years,whichever occurs first: 5/1 B/13 <br /> Coropliance questlons/criterla: (Required) Verlflcatfon Method': (Optio�al) <br /> Check the a � riet�box _ (Check the eppropriete box) <br /> Does the system dlscharge sewege to the ❑Yes � No � Searched for surFece outlet <br /> round surFece7 ._ <br /> "'– ❑ Performed hydreulic test <br /> Does the system discharge sewape to draln ❑Yes � No <br /> tile or surface weters? � Searched for seeping in yard <br /> Does the system cause gewage backup ❑Yes �No � Chedced for badcup in home <br /> into dwellinp or est�blfshment? _. ❑ EXcessive ponding in soil system/D-boxes <br /> Do nther elUuatfon�exiet that have the ❑Yes � No ❑ Homeowner tesUmony <br /> potentlal to fmmedfetely and adversely <br /> impad or threaten public health or satetp ❑ Exemined for surging In tank <br /> (eledrical,unsafe covers�etc. ?� <br /> ❑ "618ck sofl'above soil dispersal system <br /> Any�•yos"answrer lndfcet�ns that�syst�em/s an Imminsnt <br /> th,ss!t�n public heelth and sefaty. ❑ System requires"emergenc�l'pumpi�g <br /> --� ❑ Pertormed dye test <br /> Does the system pose e threat to ground �Yes � No � pther: <br /> water for any oonditions deemed non- —""'-- -- <br /> ective es determined b ihe ins or7 „�,,,_„, _ <br /> „Yes"indicetea lh�t the sys�n is failing fo proi�ct _ <br /> ground water.N"yes';dascr/be�ho cond/don nol�ed: <br /> 'No standaid pr�toco/exists. This lisf is not exheus6ve, <br /> in sequen6al order, rror does if lrrdkete which <br /> combinetlens are necessary to make this detem►IneHon. <br /> Cert�fication <br /> This form is to be oompleted and attached to the Summary Form of the Mlnnesote Pollutlon Control Agency's(MPCA)Compllance <br /> Inspectlon Fvrm for Existinq Subsurface Sewage Treatmant Systams. Obaervetlons, interpretativns, and condusfons must be <br /> completed by an inspector. Campleted fomi must be submitted to the Iocal unil of govemment wlthin 15 days. <br /> PropeRy owner name(s): Kenneth Zagzebski <br /> Prvperty address: 2700 Copperview Drive, Orono,MN 55356 <br /> Property owners addre�s(if ditTsrent): <br /> County: Hennepin Phone: , 612-203-8473 <br /> I hereby certily that!personally made the observa6ons,interpn9tafions, and aonclusions�sporled on this fonn and thef fhey are <br /> correct. <br /> Name: Joseph J.Olson CertificaGon number: 1255 <br /> Business license neme end number Rusty Olson's soil end perc�letion beatlng Lic#810 0� <br /> Name af local unit v . ' of Orono �„ ___� <br /> Slgnelune: Dete: 5/25/10 <br /> wq-wwlsts4-31 Compllance Inspectfon Form�or Exlst�ng SSTS <br />