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06127/2069 12:39 7634988290 RUSTYS PERC TESTING PAGE 65 <br /> Paroel number _ Syslem status: �Compliant ❑ Noncomplient <br /> (as dsf�rmined by this form) <br /> Soil �eparatlon Compllance snd Oth�r Con�plian�co <br /> Compliance Issue #3 of 4 <br /> Date of ob�nration: 8/28/09 � Reason far oDsenretlon: Property Transfer <br /> This inll�rme6�nn on this fia►n does not expire. <br /> Compliance questlonslcrlteMa: (Required) VerHicatlon Method"`: (Optional) <br /> __. Ch�ck the a riate box (Check the epprop�ete box) <br /> For systems built prior to AQriI 1, 199B,and not � Conducted soil obsetvetion(s)(attach boring loga) <br /> located in Shoreland or Wellhead Protection <br /> Area or not serving a food,beverage or ❑ Two previous veriflcations(eltach boring logs) <br /> lodging establishment: <br /> ❑ Other: <br /> Does the eystem have at least a twafoot <br /> vertical separation dlstance from periodically <br /> seturated eoil or bedrodc7 Yes No <br /> For non-perFormsnce systems built Apnl 1, <br /> 1986,or leter or for non-perFormancs systems <br /> located in Shoreland or Wellhead Protectio� Soll obaeivedon does nat expire. Previous observetions <br /> Areas or sen►Ing a food,beverage or lodging by two independent parties are suffident, unle�s site <br /> �stebHshment: condltions heve been eltered. <br /> Does the system have a thre�foot vertic�l <br /> s�psration distance from periodicelly setureted <br /> soil or bedrocic?' Yes No <br /> For reduoed separation distance syBtems(i.e., <br /> "pertormence'systems under old 7080.01 T9 or ' Mey be reduced by up to 15 pe�ent if allowed in local <br /> Type IV or V system under nsw 7080_2350 or o►+dinenoB, <br /> 7080.2400): "No stendeid pmtocol exists- This list is not exheus6vo9, <br /> Does the system meet the designed vertica) in sequential order, nor does it indicate which <br /> separetlon dlstanos from periodically saturaled combinations are necessary to make this <br /> sofl or bedrodc?' Yes ❑ No det�emrinetiasn. <br /> Any"ra'°a�sw�r!ndlcobr,s UNt tl�s system/s fall/ng to p�tact <br /> ground wadtr. <br /> Certtficatlon <br /> This form is to be completed and attached to the Summary Form of the MinnesOta Palution Control Agency's(MPCA)Compllance <br /> Inspection Fom�for Exlating Subsurfece Sewage Treatmerrt 3ysts�ns. Obssnrations,intarpretatlons, and conduslons must be <br /> complerted by an inspector or designe�.Completed fortn muat be eubmitted to the locel unit of govemment within 15 days. <br /> Prope�ty owner name(s): Cathe�ine Johnston <br /> Property address: 940 Brown Road S Orono MN 66391 <br /> Propert�r owners address(if ddfererrt): <br /> County, Hennepin Phone: 612-77a1788 <br /> I he►eby certfly tha�I peBoneUy mede the obse►vaElor�s,lnteip�tatiens, e�a�i�o�s�o,t�o�m►s r�m,e►�d mar tnay a� <br /> conect <br /> Name: Joseph J_�Iso� CertlftiC9bon number 1255 <br /> Business livense�eme and number: Rusty Olson's soil and perculation UestinA Lic#810 _„�„ _ or <br /> Name of locsl unit o ovemment: City of Orono � <br /> Signehire: .�,. .w.�..�..�,. Dete: B/27/09 <br /> wq-wwlsts4-31 Compllance InspecNon Form jor Exls[ing SSTS <br /> A///AO <br />