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04/15/2010 11:58 7634988290 RUSTYS PERC TESTING PAGE 12 <br /> Parcel number: 041172 System status: ®Compliant ❑Noncompliant <br /> (aa detemdned by this fort) <br /> soil Separation Compliance and Other CoMpilatnco <br /> Compliance Issue #3 of 4 <br /> Date of observation: 4112110 Reason for observation: Transfer <br /> This inkmis ton on this tbnn does not expire. <br /> Compllamn queationslcriteda: (Required) Verification Method"': (Optional) <br /> Check the 9MMgpnote tax (Check the appropriate bob <br /> For systems built prior to April 1, 1996,and not ® Conducted soil observation(s)(attach boring logs) <br /> located in Shoreland or Wellhead Protection <br /> Area or not serving a food,beverage or ❑ Two previous verifloations(attach boring kgs) <br /> lodging establishment: ❑ Other. <br /> Does the system have at least a two-foot <br /> vertical separation distance from periodically <br /> saturated soil or rock? WYes No <br /> For non-performance systems built April 1, <br /> 1996,or later or for non-pertorntanoe systems Soil,observation does not expire.Previous observations <br /> located In Shoreland or Wellhead Protection by two independent parties are suftident,unless site <br /> Areas or serving a food,beverage or lodging conditions have been altered. <br /> establishment: <br /> Does the system have a three-foot vertical <br /> separation distance from periodically saturated <br /> soil or bedrock?' Q Yes 0 No <br /> For reduced separation distance systems(.e., . May be reduced by up to 15 percent if allowed M kocel <br /> 'psrfonrW1W systems under old 7060.0179 or orctnevu�e <br /> Type IV or V system under new 7060.2360 or <br /> 7080.2400): "No standard pratvcW exists. 7 is list is not exheusUve, <br /> Does the system meet the designed vertical in sequential order,nor does it kx kete which <br /> separation distance from periodically saturated combinations are necessary to make this <br /> soil or bedrock?' Yes No detemVneffon. <br /> Any"no"sne wr hrdkaf►es shat the lysftm 191 OMM9$0 pnobct <br /> pvued rweW. <br /> Certification <br /> This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compliance <br /> Inspection Foran for ExiOng Subsurface Sewage TrsatrneM Systems.Observations,Interpretations,and conclusions must be <br /> completed by an inspector or designer.Completed form must be submitted to the local unit of government within 15 days. <br /> Property owner name(s): Baker Homes Inc. <br /> Property address: 3085 Watsrbwn Road. Orono MN 55359 <br /> Property owner's address(if ditrw t): <br /> County: Hennepin Phone: 1351-276.0413 <br /> I hereby certyy that I penWORy made the observations,intMIM660ns, and eo"okmions reported on this fiwrn and that they ane <br /> aoneot. <br /> Name: Joseph J Olson _ Cer88cation number: 1255 <br /> Business license name and number. Rusty Olson's sail and percolation lessino Uc*810 or <br /> Name of local un' gvvemrnent: City of Orono <br /> Sero: Date: 4114/10 <br /> wq-ww1sts4.31 Comptlance Inspection Form for Fidsting SS75 <br /> 414108 <br />