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12/08/2019 69:57 7634988296 RUSTYS PERC TESTING PAGE 03 <br /> Peroel rnmber- Sys6sm stetus- �Complierit ❑Nonmmp�nt <br /> (as aetem�lr�ed py n�►s rorml <br /> M�IIc P�ri'On�a�o! a�ld OthK Co��plia� <br /> Compliance Iswe #1 af 4 <br /> Data of observ�fon: , 1Z/03R010 Res�on tor oheeiva�Hon: P Trerisfie� <br /> This fiorrr►expires upon next Inapec�on ar in tht�ee yests,vrFi�cfiev�u�cur6 first: 17J�03113 <br /> Compllanai�qusstio�alcritsri�: (Requ�►ec� VeNflcs�lon Mstl�od': (�p��) <br /> Chedc dtie bax ((aNedc the app�qpriet+e box) <br /> Uoes 1he syStem dschsrge$e�eAe to tl�6 ❑Ye6 �Nc � S89�ched fOr surfeCe outlet <br /> round suAaoe9 ❑ Pe�mree hydreu�c test <br /> Daes 1he system�isd�uge sewa0e to dre� ❑Yes �No � �for seeP�n9 in yerd <br /> dle or surfao�water8? <br /> Ooes the sya�em c�use aewa9e badwP ❑Yes �J No � Chedced frn badcuP in home <br /> into dwelf or eatablis�m�r�t7 ❑ E7oceasive Pondin9 In soil systemlD-boxes <br /> Do ofher�Sdons eudst that heve the �Yes �No ❑ Homeaw�er tessiimonY <br /> ppteritlel 6o immediet�ly and adversely � F�caMned Gor surging In tank <br /> imped ot Ux�t��P�ic heeHh or safety <br /> eledtical ur�asfie covets oCC.? ❑ `Bledc sa�l'ebove sofl diaps�sei sYstem <br /> Any~ya�"unswar/nddreebas tl�t fM sya�snr ti asn lmnlU�e�nt <br /> �rsut eo publta hadq�snd sa1�eRY ❑ System i'aQufres"eme�D��9 <br /> ❑ Performed dye teat <br /> Does�e sys6am Pose a 1h�at fio giamd ❑Y� �� � Olher. Petetson Ca� <br /> w�er�or arry oo�deemed nor►- <br /> s� � <br /> pre:p�ndksa•nnr�.:y�+s�r�p+� <br /> yround w�tsr.N"y�ea;ak�dibe tl�e condltlon notad: •No standartl prodvcd exists- This list fs rrot exheusNve, <br /> in sequerHiel order,nordbss it indl�cete whlch <br /> i Canbinatfonrs al+s neoessary to make dris def�e►minetia►- <br /> I <br /> ���f��011 <br /> TNs t�am is to bs oomplelad and sf�dtied�o the Summery Fam of ths�PcNueon Canlrol Age�S�A�m�i�t� <br /> In�psc�ion Fomt 1�or E�tlrg�ubsurfscs S�ewa9e Tn�lm�nt 8�Mna•O�e�va0o�.�Pf°�O^6' <br /> ��►��p�r•Compledad iam nwst bs aubmiued�bo n,e 1oc�l unit af government witlrin 1 s days. <br /> property owner neme(s): Matt 8 Carrle VanSlooten <br /> Property e4clress: 3g4p Jacobs Nrll Rosd,Orono MN fi5356 <br /> properly owner'S address(if dillbrent): <br /> Counry: Hennspin Phone: 612-309�6Lti22 <br /> I1 here�b,y c�erd�►y thet I per�o�rieNY rriede the ob�ve6ons�s,and oonc�ons reported on tl Ns fam and riret dhey eis <br /> cQir�ct <br /> Nal�e: Jo�h J Olson -- CerqAo�ion rnr�er: 1256 <br /> B t re i n e a s R o e n s e n a m e and numbor: Olson's 9od and Dena�ion�l.ic�F 810 _ , .,.� ar <br /> Name of Iocel uni ov�m�� C of Orono <br /> Signsbune: , _ . Dass: 12/08/10 -- <br />� <br /> I <br />� _ . _. �Nne�linrro In.sneetion Form for Exlstfn�SSTS <br />