2009 - compliance inspection form (SSTS)

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04/18/2009 14: 30 7634988290 RUSTYS PERC TESTING PAGE 05 Parcel number: 33-118-23-41-0007 System status: ® Compliant ❑ Noncompliant (as determined by this form) Soil Separation Compliance and Other Compliance Compliance Issue #3 of 4 Date of observation: 9/3/08 Reason for observation: Property Transfer This information on this form does not expire. Compliance questlonslcriterla: (Required) Verification Method": (Optional) Check the a.• trate box (Check the appropriate box) For systems built prior to April 1, 1996,and not located in Shoreland or Wellhead Protection ® Conducted soil observation(s) (attach boring logs) Area or not serving a food, beverage or ❑ Two previous verifications(attach boring logs) lodging establishment: 0 Other: Does the system have at least a two-foot vertical separation distance from periodically saturated soil or bedrock? ■ Yes p No For non-performance systems built April 1, 1996,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 sufficient, 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 If allowed in local Type IV or V system under new 7080.2350 or ordinance. 7080.2400): `•No standard protocol exists. This list Is not exhaustive, Does the system meet the designed vertical in sequential order, nor does it indicate which separation distance from periodically saturated combinations am necessary to make this soil or bedrock?* 0 Yes ►ii No determination. Any"no"answer indicates that the system Is falling to 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): Foreclose Property address: 2550 Woodhaven Drive Property owners address(if different): County: Hennepin - Phone: I hereby certify that I personally made the observations, interpretations, and conclusions reported on this form and that they are correct. Name: Joseph J.Olson Certification number: 1255 Business license name and number: Rusty Olson's soil and perculation testing LIc$810 or Name of local unit ovemment: Ci of Orono Signature: Date: 4/09/09 • wq-wwists4.31 r'mmnlrnnro Incrwrrfnn c,...n /nom r..,..i,... crrr