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01/19/2007 23:06 7634988290 RUSTYS PERC TESTING PAGE 04 Pull Ownw(s) Ran NoOM Site Address: 11,185 Yftndamere Road. (Pxieashe desaft the syg m components): tank.2-AMUWmately 1000 Gallon#9Ak 1 appMWnytely 1,000 aallon 11t sbftn,and figRWA INN 1500 what metlroda ware used to make the determinations for the oornplanae Irrsp i Ion?(Alam:Aro SAWh*rd pvatooal the MMM i is not OVOUStive,not in ahequerfbk 1 a-dw nor wt**WngF atfMW are necessary to mwke a determb4bion) l�Y6»illl'IL0) D Probed tank bottom © Searched for surface outlet a Conducted soil borings v Observed low liquid level a Performed hydraulic Lest Depth to limiting layer SM O Examined const.records O Searched for seeping In yard Depth to system bottom&M O Examined em;�ty(pumped)tank O Chedced for back-up in home o Examined records o Probed outside tank for"black soil" o Excessive ponding In soil system/D-boxes o LGU Limiting Layer Verification o Pressure/vacupm check v Homeowner testimony o Other p Other O Examined for surging In tank a `Olack soil'above soil system 0 01;her S1ta)t11S Oaf tlf!aystem UWW an the CMpllanee Cdlb ria,the syOetm status Is: (check one) 0 falling (to protect groundwater) ❑ an Imminent threat bq public health or safety(MMS), ❑ non-compliant(monitoring issue). W compliant(non-of the 3 previous condtlons). Is this system a EP4 Clan V Injection WWI? ❑ yes Or no this document Is a: It Certificate of Compliance O Noft of Noncompliance I hereby certify as a State of Minnesota licensed Inspector and/or Designer I or Qualified Employee Inspector and/or Qualified Employee Designer I that I conducted an investigation that apourately determined the compliance status of this system and that my recorded observations are accurate as of this date. No determination of future hydraupc perfamwee has been nor an be made due to unknown conditions during system conshuMon, of the systen.inadequate maiMhenanoe,or future water usage.' i inspectors name(print) JlIwiagh 3 01 n Phone: (7St3)41984179 Ucense and(or Registration Number 210 Address: JjA1 gbMX3d=RCM ME,.Hnnft%j�HN,55341 Em by. Sol#j PgrCid-64.—I Zmdbm Sig natu Date: 1119107 jder*edlMm Mwm'es &Sta*AVS 1115.55) An rrAS fffaW be fid,rep&ced,or oris um dlwnbnued w4hin tw scythe of aeuheipt of this nobw or within a slwater pienod If mgain9d byka/adiaano v. If Hae aystsm fans to phoadde sufffWnt graunalM1vr pvvWVW, em the system must be upgraded, n4obced,of ahs vena dacnr ift ed Aft die line required by rvk or the local orY#wx' If an eds rng system 15 not fading as defined in law,and has at least twin fleet oFdeYgn sial shW"bbn, then the system need not be upgraded,repakv4 repiloccd, or Its use &wntibued,raotwiUasbnding any kvW a llna xv chat Is more snitch Thw does not aA*to systems in shoreland areas, wellhead profecIixan arses,or these used In aonnedaa with food, beverage,and g estabhshments as defined in kw. 1) Site sketch which Includes the system location(mandatory). Other Items could Include:well,well setback to system,dwelling or other b"Ildings,tank(s),reserved soil treatment area,surface water and soil boring locations. Include as-built drawing if available. 2) Soil boring logs,showing each horizon. Indicate the texture,color, redoodmorphic features depth to bedrock,standing water and whether the material is fill. 3) A list of any and all requirements of the local ordinance that are different from the state requirements referred to on this form. 4) A homeowner survey of system performance,signed by the homeowner as being factual. 5) Monitoring data as appropriate. Page 2 of 2