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08/20/2010 15:42 7634988290 RUSTYS PERC TESTING PAGE 05 Parcel number 0411723210010 System status: ®Compliant ❑Noncompliant (as detem*W by this form) Solt Sepatrattfon Compliance and Otlw Commigmae Compliance Issue i#3 of 4 Date of observation: 8/18/10 Reason for observation: !ERM Transfer This wftrnahm on this form does not expire. Compliance questlonWadoffia:(Required) Vstftkatlon Method''; (Options!) Check the be hour (Check the e Ppmprist@ box) For systems!wilt prior to April 1, 1986,and not ® Conducted soil observation ng ) located in Shoreland or Wellhead Protection (s)(attach boring Area or not serving a food,beverage or ❑ Two previous verifications(attach boring logs) lodging establishment ❑ Other_ Does the system have at least a two-foot vertical separation distance from periodically saturated soil or bedrock? Yes ❑No For non-performance systema built April 1, 1858.or later or for non-performance systems located in Shoreland or Wellhead Protection Soil observation does not expire,Previous observations Areas or serving a food,beverage or lodging by two independent parties are suffiderk unless site establishment. conditions have been altered. Does the System have a three-foot vertical separation distance from periodically saturated _soil or bedrock?• Yes No For reduced separation distance systems(i.e., "performance systems under old 7080.0179 or ' May be reduced by up to 15 percent K allowed in local Type IV or V system under now 7080.2350 or ordinance. 7080.2400): "No standard protocol exists. This Ilst is rot exhaustive, Doss the system meet the designed vertical In sequential order,nor does it indicate which separation distance from periodically saturated coembinaaons are necessary to flake this soil or bedrock?* D Yes El No determination. Mdkoft OW the s~is failM9 to pmjWt Certification This form is to be completed and attached to the Summary Form of the Minnesota Poqution 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): Michael Francis Property address: 2955 Watertown Road Orono,MN 55356 Property owneys address(if different): County: Hennepin Phone: I hereby 0e1tfly that I personafy made the observations, lnterpretaucm,and conciuslons reported on this form and that they are coned. Name: Joseph J.Olson Certification number. 1255 Business license name and number __RugjOWWs9oilsndpercu itiontestIngLic#810 or Name of local unit moment: City of Orono G-' Date: 8/20/10 wq-wwlsts4-31 Compliance 1 pl nWecbon Form for Existing SSTS