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01/1012e�i2 13:06 7634988290 RUS-I-YS PERC TESTING PAGE �5
<br /> �arcet�zumber: 0�117-�342-0010 _ System status: �Compllant ❑No�c�ompliant
<br /> _._ (aa dete►mined by nhis iorml
<br /> Sotl �►paratlon Corrrpllaneo s�d O�her Con�pllance
<br /> �orr�pf�ante Issue #3 0� �4
<br /> i�ete df ob�erveUon: 1/20/9� � Re��on for obeervation: Pro�er�Trensfer , �, �.
<br /> 7'P�is tnlbrmeflon on this fiomr does not e3rpi�e.
<br /> Ce�i��i��noe qua�tlonslc�fteria:(Requ�ree) Verlflcation MelhodR°: (OptionelJ
<br /> (Ch�►ck the ep,�ropri�te box) _ _, (Check the appropriete box)
<br /> F�r�ys�ms built prior ta April 1, �i 996,and not � Conduded soil obs�rvation(s) (attach boring lop�;)
<br /> Ic�cs��d ir�Shoreland or Wellhead Proteetion
<br /> Are8 ur�iot eerving a fiood,bev�r�ge or ❑ Tv�ro previous verificatlons(ettech bvring logs)
<br /> iadQing astablishment: ❑ pther: ,_ ._.�
<br /> Do����s��ystem have at I�est a Mro-fi�ot
<br /> v�riicad�eparation distance fi'om perlodicelly �",-.--... -'""'---
<br /> .. ,_.
<br /> s�lurat�l soil orbedrock?. []Yes No '
<br /> Far rs�rcr-�rformance systems built April 1, ,�„..� -- �--
<br /> 19�,cr l�ter or for non�perfom�ance syaiems
<br /> 1�:".;�In Shoretand or Wellhead P►vtection ����akian does not exQir�e,Previous ob�ervetiots$
<br /> �r����s c�r senring a food,beverage or lodging b�r two independertit pa�es are suAident,unless site
<br /> �st�biishmen�: wnditions have been eltered.
<br /> I�a:3a t��systsm h�ve a thre�foot vertical
<br /> s�p�zrr�ttipn dist,anoe from periodic�lly satureted
<br /> s��l:�r-tsedcvck7• _ .___W�„- _ Yes No _
<br /> Frsryreduc�d separatio�distanc�systems(i.e.,
<br /> "p�rfibe�i�n�"�systems undar old 7080.0179 or ' May be reduced by up to 15 pencenf if ellowed in lacal
<br /> ryl�IV or V..s�rsiem under ne�.v 7080.2350 or o�rNneaoe.
<br /> ,,: ___ _- ._._
<br /> '�J�): ••�vo stenderd pioro�ca exisrs. Tnis Jfsr rs nor exnausbve,
<br /> [�=a,'�«'�ystem meet the desigr��d vertical in aequentfal ader,nor does it indic�te which
<br /> ,• canbinatians en�neces�sery,.i�make this
<br /> sa�s�z��rdn distance f�nm periodicaally saturated .,..,
<br /> soiE sir h�drock?' ❑Yes No delem►lnetion.
<br /> ...- .c ��;,-:.
<br /> �r�%.�.��rt�r�r hrdKa¢�ae th�Y�syst�am la lS�NIn�b�piotect
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<br /> � ; . . ��;i;r.sr�r���ua�tie ,�,s ;;�'«w�1�..;, :����iriti�Rr���,�1
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<br /> ... � �4'.;' � .. .. . ,� . . . . . . l..': ...�'i1�l�irA1����t6�C l•:d�;1Y�'t��E wi�..l . .�:���' .
<br /> ��'����ation
<br /> �_,�:� � T4: ,..�. ..
<br /> T�is fprm,is to,be completed and attached to the Summ�ry Form of the Minnesata Pallution Control Agency'�(MPCA)Compllan�e -
<br /> In�par�tic� Form for Exlsting Subsurface Sewa�e Treatrnent Systems.Observations,interpretations,end conclusions muat be
<br /> _._._.__., . ._
<br /> �ni�Eet�d by en inspedor or deaigner.Completed torm must bs submltted to the local unit of govemrnerit wlthin t 5 deys
<br /> ;, ; , �. .,, _
<br /> , ,.
<br /> Fru�,�r���ty awner name(s): J�M�Greely ._— r M r�
<br /> �,.z •,
<br /> ,� . . , „��..--
<br /> A��,�
<br /> �'�;s�►ty adcin�s: 420 Brovun Road S Orono,MN 55391 ` ''�� �;;, .� ;��
<br /> .. ___ ��;
<br /> �ra�o�y ovsmers address(tf ailrerern): 14506 M�Gint�Read W_Minnetonka, MN 55391 , .
<br /> ui.,: .
<br /> �q�. y r ' ',H�nnepin, ,. Phone: 952-933-2818
<br /> �,, �. �.,.....�._— . -- •
<br /> r�iQr��y�cam ,,
<br /> '�yy that 1 porsonslly made fhe obse�vatlans, interprefations, and cvnclusiQns nepoited on this form and that they a�
<br /> � �. ,�.
<br /> . ,
<br /> car��ct
<br /> . � . .r�...:�; _ � , ..,.�.����:
<br /> ;,., �, ,, . .
<br /> �i�j�j�� �Jo�ph J.Olson "'' Certificetion number: 1255
<br /> ,x. . _ .,'t' � , .„ , e � � ,rlX.�lD i�9,
<br /> Buair�ess Ilcense neme end number: Rusty Olson'a soil and perculation testln�Llc#810 . _ or
<br /> .,.)4P; .�G� s�l�, .,�� , , .. .. 4(,� . .
<br /> IV��a�ofiocat'u�it emmerr�:J Ci ofOrono _a. � ,: s:.;. :;;.. .----.–
<br /> . : ��, � -,
<br /> ���� :
<br /> Sigr��,�re: Date� 1/20/12
<br /> . ,3r r� ,tia' . ,n�r;, . 9�r r . . - ....
<br /> .��:d.''J��r i.,.... .
<br /> �,;.wnu,tcrca.�� [omnllance lnsnection Form for Ex�stina SS I S
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