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_ ____63j�2/2011 17:52 7634988290 RUSTVS PERC TESTING PAGE 03 Parr,el number. 04'�1723130014 _ , SysTem status: � Compliant ❑ Noncompliant (as det�ermined by thls fo►m) IHydr�u�ic Performanco and Other �ompllance �ompliance Issue #1 of � Date of observation: 3J1/2011,,. �leason fior observaiiorr „ Propert r�Transfer ,,__ ,.___ This form e�ires upon next insp�ctinn o�in tty►-�e years,whic:hever oowrs 5rst; 311/14 „ .— �ompli�nee questions/cNterla: (Required) Verlflcation Method": (Optional) _�Chesk Hi��PP�P►iate bac) .. ,_ ,-- (CheCk the eppropriete boxJ Does the system discharge sewege to the ❑Yes � No � 5earcJied for surface outlet , rog und surface? _._, _ _. - ❑ Perfonned hydraulic t�st Does the�syste�m discharge sewage to drain ❑Yes �No _tlle or surFace W.aters7 _ � Searched for seeping in yard � � Checiced far backup in home Does the syet�m cause sewage backup ❑Yes ISI No _into dwellin n _estsblishment? ,, ❑ Exoassive ponding in soil system/D-boxes Oo other situ 'ons exist that have the ❑Yes � No ❑ Homeowne�testimony potential to i ediately and adversely impact or th ten public health or safety ❑ Examined for su�ging in tank electricel un afe covers,etc.)? . — ❑ "Bladc soil'above soil dispersal sysiem Any"yyre�" indka�es Uwt tl1a systan fs an lmminerrt d��6 ��, ❑ System requires"emergenc�'pumping _ ,... - ❑ Performed dye test Does the sys m pose a threat to ground ❑Yes � No � pther: Peterson Company _ water fior any nditions dee�ned non- " � �rotective as etermined the Ins o� ., __�. .., - _._—..--- ��Y�s"indlc �at�e syst�m!a failinq ro proloect �... _ .... __ .:.....—... ..-- �roa�nd wa . If"yes",dosc�b�the candlNon noted: 'No stenderd prvtocol exists. This list is not exheus6ve, , ,., ..,. ... in seqtieritiel order, nor does it irrdJcete which � combin�Nons a►e rrec�ssery t+�make fhis determination. Certifica on This form is be comp�eted�nd attached to the Summery Form of the Minnesota Pollution Control Agency's(MPCA)Compliance Ir�gpecdon Form for F�ci6ting Subsurtace 8ewsgo TreatrneM Syatems. Obsen►atlons, interpretations, and conclusions must be campleted b an inspec�or.Completed form must be submilted to the local unit of govemment within 15 days. Property r name(s): � ht Post „_ -– _.—_ „ _ - — 1 Property ss: 2755 Oee Run Treil Eas1,Orono,MN 55356 ., _...._ Property rs addre�s(►f d rer�t): County: nne in I _,_ _ Phone: 812-747-0283 _ „ , 1 hereby ce that 1 p�rsonall made the absenre6ons, inte►pn9fations, end conclusions�ported on this form and that they are corr�Ct, i �� Nsm J e h J.Olson __--- _._._...... Certification number: 1255 _._._.._._ Busi�ss li se name and nu be�: Rust�i Olson's soil and perculatton teg�ng Lic#810 __. W, or I ___.___ ,.,,� . tdar�of local unit of govem ; City af Orano �---- —� ,.......— ---- ..,. . Sig � re: Date: 3/2J71 W...��r�dz� I �mm��iance Insnectian Form for Exlst�nQ 5Sl"S