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11112912011 18:57 7634988290 RUSTYS PERC TESTING PAGE 05 Parcel number 3311823440040 System status: ®Compliant ❑Noncomplient (as detemarred by this form) Soil Separation Compliance and Other Compliance Compliance Issue #3 of 4 Deb of observation: 11/29/2011 Reason for observation: Property Transfer This flfmabon on this form does not expire. Compliance questionWerfterla: (Required) Verification Method"": (Optional) (Check the appropriefe box) (Check the appropriate box) For systems built prior to April 1, 1988,and not ® Conducted soil observations)(attach boring logs) located in Shoreland or Wellhead Protection Area or not serving a food,beverage or ❑ Two previous verifications(attach boring lags) lodging establistwom: ❑ Other: Does the system have at least a two-foot vertical separation distance from periodically saturated soil or bedrock? 0 Yes No For non-performance systems built April 1, 1996,or later or for non-performance systems located in Shoreland or Wellhead Protection SO observation does not expire.Previous observations Areas or serving a food,beverage or lodging by two independent parties are sufficient,unless site establishment conditions have been altered. Does the system have a three-foot vertical separation distance from perlodicaly saturated soil or bedrock?' N Yes El No For reduced separation distance systems(i.e.. 'performance'systems under old 7080.0179 or ' May be reduced by up to 15 pervent d slowed in local Type IV or V system under new 7080.2350 or oromance. 70802400): "Ilio standard protocol exists. This list is not exhaustive, Does the system meet the designed vertical In sequential order,nor does d indicate which seperetion distance from periodically saturated combinations are necessary to make this soil or bedrock?' I LJ Yes No determination. Any"nos answer Indkataes that dna sysbm is falift so protect ground water. Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compliance Inspection Form for Existing Subsurface Sewage treatment Systems.Observations,interpretations,and conclusions must be completed by an inspector or designer.Completed form must be submitted to the local unit of government within 15 days. Property owner name(s): Tim Corrigan Property address: 155 Tnrflale Trail,Orono, MN 55356 _ Property owner's address(if dltlerent): County: Hennepin Phone: 952-475-0881 I hereby certify that I perronely made the observations,intarpretabonA and cowumns reported on flus form and that they are Coned. Name: Joseph J.Olson Certification number. 1255 Business license name and number Rusty Olson's soil and perculabon testing L.ic#810 or Name of local mment: City of Orono �... Signature: Date: 11/292011'. wq-wwists4-31 Compliance Inspection Form for Existing SSTS