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. 05%25/2010 12:18 7634988290 RUSTYS PERC TESTING PAGE 04 <br /> Parcel number: SyMem Stetus: �CorrapliaM ❑Noncomplla(ii <br /> (es deiemri»ed by thfs fia/m) <br /> Hydraultc P�rtom+a�ec� and Other Complianc� <br /> £o�ptia�e�e l�saee#'� �€4 <br /> Date af obser�atlon: 527I10 R�6on for ebsenation- PropeRY T►ansfer_ <br /> This form expi►es vpon nent inspe�t�vr+or ir���rse yeata��ever ncuxs llraL' SJ21/13 <br /> Compfiance questions/c�{tar1A: (Requirecn Ve�ffic�atforr Methdd':(Optione9 <br /> Chedc the a m riate bo (Check the appiopiiate box) <br /> Does ths system discharge sewege to the []Yes �No � Searched for surfac;e oudet <br /> und sutfac:e? <br /> Q performed hydraul'�c test <br /> Does�e system discharge sewage to draM ❑Yes �No <br /> tile or su�face waters2 � Searrhed for BeeP�ng in yard <br /> Does the system�use sewege backup ❑Yes �No � Checked for backup i►t home <br /> iata dw�eNi or estaW�shmenC� _ � ���po�ding i�soii system/D-boxea <br /> Do other eituatiw�s e�ast thet hava the ❑Yea �No ❑ Homeowner teatimo�y <br /> poter►tlal to immediately and adversely <br /> {nspect or threaterr publlc health or safely I ❑ Exemined for surging in tank <br /> �el�dric�� unsefe oovers,etc.)? ❑ Bladc soil"Hbove sdl d�spersal system <br /> Anr"�s'aRSNre�/nd/Cptas fhYt L►w aysEe►r►fs en ImI1H�aItt <br /> �rest to pubUc haalth atrd sufee�r. ❑ ���Q��+����P�p��9 <br /> ❑ Pertortned dye tesi <br /> Does the system pose a threat to ground ❑Yes �No � ��. <br /> water ior any conditia�s deemed non- <br /> xGve as determined b the in <br /> rtY9S��lndicstes thar tho syslam!a fiilirry to prot�t <br /> g►rwnd w�SPr.If"yes';de�sCrfbp thrsondlNon rtoE9d: <br /> 'No stendard protocd exists.This I'�St ls not exhaustive, <br /> --- ._------ -- - ._ in sequen6a/onter,,ior doea if�cat�whictr <br /> camarnedons aie necessery ro rr�ake m►s detem',ine6or►. <br /> Certification <br /> This form is to be compleled aM!�d to the Summary FOrm ot ihe Minnesota Poltution Control Agency's(MPCA)Comptiancs <br /> tnsp�ctlo�Form for Exts�n�8ubeurtsCe Srw�geTieatrnsrlt Syslsms.Observetion�,interp�+e�ta4ions,and oondusfons mqst be <br /> oass9P�eled bY art k�pe�.Cflrtiple4a�tv�+�ays4�e subrr�tteA ta�ae lec�!ua1!af eove�nmetad�aifbin 15�a�s. <br /> Prvp�rtg own�c►ame(s}: Kekh Fri�e <br /> Prapert�*addreaa: 7.5t5�Cvarmvsidgflrive,Orono MN 5535� <br /> PropeAy owners adCress('�►dNhroM): <br /> Cou�ty: Hen�eD�n Phone: 882-�476-8703 <br /> r t�e,�ar ce►vh-mat�personeuy mede me oaservaao»s.Uteip�etefiona,and cw�clusfons ieported on diis�orm and fhatflrey ars <br /> �►�t <br /> Name� Joseph J.Olsori Ceri�ficetion rnimber. 1255 <br /> 8ctsinese�1�oer�se r�a�e ar�A r�ua�: R�ty Alaar�'s soit and�e�fia�D�iic#s» ar <br /> Name of Iocal unit f g C' of Orvno <br /> Signature: Date: 5I25110 <br /> wq-ww�sts43 f Canp[ionce lnspection Form for FxIsNlrg SSTS <br /> �/4/Oa <br />