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07118/2611 17:32 7634988290 RUSTVS PERC TESTING PAGE 03 <br /> Parcel number; 331182333U003 System 8tatus: �CamP�iaM ❑ Noncompliant <br /> (e,q det�em►ined by this form) <br /> Hydraullc Portor�r�ance and Othor Co�npllance <br /> CompH�nce Issue #1 of 4 <br /> Dete of obBervation: 7/13/11 Reason for ob8ervetion: Pro e Tr�nsfer _ <br /> This f�orm expires upon next�nspectlon o�in three years,whichever xars flr8t: 7/13/2014 , <br /> Compll�nce qu�tjons/ciiberia: (Required) Va�ification Mvthod": (optional) <br /> , (Check the aQ�►oprfate bax) (Check the�ppr�priete box) <br /> Does the system discharge sewege t,o the ❑Yee �No � �e�ed for surface outlet <br /> ground surtace? .. ❑ P���Aydraulic best <br /> Does�e system discharge sewage to drain ❑Yes � No <br /> tile or surfaoe waters?_ „ � Sea�d�ed for eeeping in yard <br /> Does the system cause sewaga�ac�cup ❑Yes � No � Chedced for badcup in home <br /> into dwellina_or establishment?____ �] Excessive ponding in soil syetemlD-boxec <br /> Do other situetions e�ust that have the ❑Yes � NO ❑ Homeo�wner testimony <br /> poterrtial to immediately and edversely <br /> impact or threaten public health or sefety [] Examined for surging{n tank <br /> (elecirical,uneafe covers,etc.)�___ _. [� •g�e�$pil'above soil dlspersal system <br /> Any�•yes"'anawsi Mdka�ea tl�at the system is en Immin�rrt <br /> �������� p System requires'emergenc�'pumping <br /> _, . ,_ � � PerFormed dye test <br /> Qoea the system pose a threat to ground ❑Yes � No � pther. <br /> water for eny mnditions deemed non- <br /> protedive as defiermined by the in�pecton,,. __ . <br /> "Ye9"1ndMat�sss that dte jy�bwn Is fe/llny t+o profoct _ <br /> �round wabe�li"�",d�ecrlbe fhe cond/tlon nobed: <br /> 'No standard p►vtovd exisls, This list is nol exhaustive, <br /> ,,.,� . In sequer►t�al ader, nor does it!nQlca�e which <br /> � combinations a►�rrecessary to meke thls detem►inadon. <br /> Certification <br /> This form is to be completed and attached to the Summary Fortn af the Minnesote Pollution Cantrol Agency's(MPCA)Compllonce <br /> fnspection Fortn fo�Exlstine Sub�urface Sewage TrQatment 8ystiema.Obsarvetions, interpretations, and candusions must be <br /> compleDed Gy en fnepector,Compl�ted form must be submitted to 1he local unft af govemment wlthin 15 days_ <br /> Property ow�er name(s): Doug�a�Reynolds .. <br /> propeRy address: 75 Crystel__Creek Road Orono MN 55356 <br /> Property owners add�ess(if dil�erent): <br /> Cuurtty: Hennepin _ Phone: 612�25-2570 <br /> 1 hereby ceNly thet I personelty made the observa8ons, inte►pretations, end ca�c�usions►�orred on mis so��►►d�►er m�y a►e <br /> conect. <br /> Name: Joseph J.Olson __ _ Cerbification number: 1255 _ <br /> Busi�ess lioense name and number. Rusty Olscm's goil and pe�ulation b9stln{�Lic#810 or <br /> Name of local unit of govemmeM: Cfty of Orono __ ,_. _„ _ <br /> ..:..,.. <br /> Signeture:� _._. Oete: 7/15/11 <br /> wq-wwists4-31 Canpliarxe Irtspection Form for Existtng SSTS <br />