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MINNESOTA Minnesota Department of Health RECE 770 M D1-IWell Management Section SEP 10 2014 P.O. Box 64975, St. Paul,Minnesota 55164-0975 DEPARTMENToFHEALTH 651/201-4600 or 800/383-9808 CITY OF ORONO Certification of Buried Sewer Construction and Testing This form must be completed and submitted to the Minnesota Department of Health (MDH)for installation of a buried sewer located 20 to 50 feet from a water-supply well, or the installation of a water-supply well located 20 to 50 feet from a buried sewer. NOTE: A 50-foot minimum separation must be maintained between a water-supply well and a buried collector or municipal sewer, an unapproved sewer, or a buried sewer serving a facility handling infectious or pathological waste. Owner of Property Where Sewer is Located(please print) /)c1 ref) 000e ; 0 Street Address,City,ZIP for Property Where Sewer is Located County Name Township No. Range No. Section No. Fraction ��/1/) 1/4 1/4 1/4 Date of Testing(mm/dd/yyyy) Person(s)Present to Witness Testing Well Information Provide Minnesota Well and Boring Number(s) .5—PAY 4/3 / ,s'y C/ or, if unavailable, provide the following information for each well located within 50 feet of the buried sewer. Well Well Year of Well Contractor Well Address Well No./Description Depth Diameter Construction Company Name (if different from above) Variance Information Was a variance issued by the MDH for this sewer or well installation? ❑ Yes g No If yes,please provide the variance tracking number: TN Sewer Materials ❑ ABS (ASTM D2661) ❑ ABS (ASTM D2751) ❑ ABS (ASTM F628) IN PVC (ASTM D2665) ❑ PVC (ASTM D3034) ❑ PVC (ASTM F789) ❑ PVC (ASTM F891) ❑ Cast Iron Test Methods (check one) [XI Air Test(5 psi constant pressure for 15 minutes). ❑ Manometer Test(1-inch water column). ❑ Hydrostatic Test(for plastic pipe only). The portion of the buried sewer system tested is described as follows (please specify each segment of sewer pipe which was tested). P C=ss TO k. TU ae Ni.:ti ;‹, Please draw a diagram of the sewer system on back and note the locations of any wells and the portions of the sewer system that were pressure tested.