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63/06/'2012 13: 25 7634988290 RUSTVS PERC TESTING PAGE 03
<br /> Property address: 1486 fox St., Orono,MN , InBpector initials/Date: J_0_3/06/12
<br /> 1. Impact on Publit Health—Compliance oompQnent�1 of 5
<br /> CompliA�ce criberi�: � V�Nfication method(s�;
<br /> System dlscharge sewage to the ❑Yes � No � �e���r surface outlet
<br /> round surtaoe. � Sea�ed ior seeping in yardlbeckup in home
<br /> Syst�em d�sd�erge aswage b drglr�ble ❑Yes Q�No ❑ �^�P°^ding in soil sy�CemN-boxes
<br /> or surtaoe waterffi. ❑ Homeowner teaUmony(see Commsnts/Fxabneeton)
<br /> System ceuee sewape bedcup iMv ❑Yes � No � �Bladc soil'ebo�ve soil dfepersal spstem
<br /> dwellfng or eetebllshment, ❑ Syatem requires'emergen�'pumping
<br /> ❑ Perivfined dye test
<br /> Any'�yss"anarwr abov�fndlcates tha ayai�vn Is ❑ u���varity�s.e awrurrenca�Exprenebn„�
<br /> an/mmJnent Thr�t te Peiblk Heakh anal Safisty. ❑ p��ry�h�s not listed(Sbe Comments/ExpMnaUwt)
<br /> Comrne�xRlanation:
<br /> _ , , _--_-.T _. .,.- - -
<br /> , �- �.,R�._.,,,�._ .._,. T;,,,.
<br /> 2. Tenk 111tegrity—Compllance camponent#2 of 5
<br /> Com Ilancs c►iterls: � VeNficatlon method��):
<br /> System consists of a seepege pit, ❑Yas �No ❑ Probed tank(s)bottom
<br /> cesspaol,drywell,or leaching pit
<br /> � �xamined construdion records
<br /> SeepaQe pits rneednq 7080:2660 mey Da [� Examined Tank InteOrfty Form (Alfach)
<br /> nt!f allowed in Ioca/wdlnenpg,
<br /> ❑ Observed liquld level belovr operatlng depth
<br /> Sewage tank(sj leak below their ❑Yea � No � �mined empty(pumped)t8nks(s)
<br /> de�i ned o r�tin de
<br /> If y�es,wh�h sewage tank(s)leaks: ❑ Probed o�s�de tank(s)fior'bladc soil"
<br /> Any`�rss"an�sw�er above fn�ce[�a the ❑ unawe to venry�s�av►�►�n��r�n�
<br /> sySi�sm is FaJljng to ProtoCt Groundwahr, ���r methms not Ilsoed(See co�n►r,ants�xp�a►�t;o„�
<br /> Cq�mm�nts/Explenadon:
<br /> tenka w8re pumped 7/8/11 � . r...,,,. ,:r ,�,,:.,: .,.;; ,
<br /> 3. Othe�Con�pliance Conditions—Campliance oompontnt#3 uf 5
<br /> a:" AAainter'►enoe hde oaverp are danwtyed,crarJoed,u►�s�ecured,or appear bo�rally unsound. []Yes' �No ❑Unknown
<br /> b., ,,Olher issues(ei�e�riical haze+�,e�.)�immedi86ely and Kn
<br /> �Y' P�D�ic heaMh or sefety: ❑Yea� �No ❑UN�rtawn
<br /> ; ;:'Sya�wn Is an finmfnant LhnAt�pudk Iwl�h artd�al�ty
<br /> ;Fxpleln: ,
<br /> c. System is non-pno�ec,tive of ground water for ufiher mnditions u determined by inBpedor p Yee• �No
<br /> -'Syate�m Is fNHng bo piodectgunundw�tar
<br /> ,.Ex�aln_ , , . ,. a ,.
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<br /> www.pt�:�[ate.mn_us • 651-296-6300 - 800-657-386I • lTY 651-282-5332 or 800�657-3864 . Avtlllab6e in altema[Me fonnats
<br /> wq�ww�sty4-31 . 1/ZI/12 .,_... � __
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