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. , RECEI 1. <br /> SEP 10 2014 <br /> Buried Sewer Testing Diagram <br /> CITY OF ORONO <br /> Please draw a site diagram ofa sewer system and all buried sewer pipes, including those buried beneath <br /> buildings (serving floor drain[,bathroom[s],laundry room, etc.).Please note the portions of the buried sewer <br /> pipes that were pressure tested,the location of the well(s), and major landmarks on the property. <br /> ) 545° .,_- i 6002Q <br /> p 1-‘414. c "P«rtt <br /> J <br /> cii - - — <br /> r � r <br /> 01 <br /> Q <br /> • <br /> Net., 0 t 64.4 4140 <br /> � I <br /> 1 <br /> I, (name) .3.611"4-5* e9<-1 , certify that the buried sewer(s)described above is/are <br /> constructed of the indicated,approved sewer material meeting the requirements of the Minnesota Plumbing <br /> Code,Minnesota Rules,part 4/15.0530, and has/have been successfully tested in accordance with Minnesota <br /> Rules,part 4715.2820,by the ildicated method. <br /> In accordance with Minnesota statutes, section 144.992,persons submitting false information to the Minnesota <br /> Department of Health are subject to administrative penalties of up to$10,000. <br /> NameTitle <br /> n <br /> CA^.eS L Qrc.►e9Lifs ann <br /> Firm � <br /> fAlcr . P� 7j$e,(1 Co 4 . t219 <br /> Street Address <br /> 5121/ Dtt y u t A u c.1 5 E <br /> City State ZIP Code <br /> e c../1o, SS,528_. <br /> License/Certification Number <br /> SAL Date <br /> ^_00`7-.2235 ig/6/ a/ <br /> HE-01488-03 origs/sewer test form.doc 2/09R <br />