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09/16/2610 10: 16 7634988290 RUSTVS PERC TESTING PAGE 05 <br /> Parcel number: 0511T23120021 Syst�em st�tus: �Compliant ❑Noncompliar►t <br /> (es detem►ined by this form) <br /> Soil Separation Con�pfla�e� and Othar Cornpllsnc� <br /> Compliance Is�sue #3 of 4 <br /> Date of observation: Z/15/10 Reeson for�: Prope�iy Tiansfer <br /> This infi�me�a►an�ii�m dnes n�ea�pWi�. <br /> Compllanc�que�tion�JcMte�it: (Required) Verfticatlon Method": (Optional) <br /> Che�k the riete box (Check the epp►oprfete box) <br /> For systems buik prior to April t,1966,and not � Conduded soll observation(s)(attach bvring logs) <br /> located in Shorelend or Wellh�d Protectton <br /> Area or not serving a fvod,beverage or ❑ Two previous verificatione(attsch boring loga) <br /> lodging esteblishment: 0 Oit�e�: <br /> Doea the eystem heve at leaat�two-foot <br /> ve�ticel separ�tion di�tance from pe�iodlcally <br /> setur�ted soil or b�dr�pck? Yes No <br /> For no�rperformance systems built April 1, � <br /> 1886,or later or for non-perfnrmence Bysf�ems <br /> localed in Shor+el�nd or Wellh�d Protecticn Sol{obsLwatlan does nol expire.Previovs observ�tlone <br /> Areas or eerving e food,beverage or lodging by two inclependent perties are s�iderrt,unless site <br /> �stabli�hmeM: cond�ions h�ve been altered. <br /> Does the system heve a three-foot vertical <br /> sepere6on distance from periodicaliy s�turabed <br /> soil or bedrock?' Yes No <br /> For reduoed seperaUon dlstance syst�m�(i.�., <br /> "perfo►mance°systems under old 708U.D179 or ' MeY be reduced by up ta 15 pen:er►t if eaowed in loce/ <br /> Type IV or V system under new 7080.2350 or Q���• <br /> ��•2��� -�!Va stenderd pio�tor.o!exists- This dst rs not euchaustive, <br /> Do�s the sy�tem meet the designed vertiCal �n�quential order, nor does It Irrd�ete which <br /> seperation distenoe from pe�iodically satu►�t,ed c�ombineha�s are n�ce�ssary t+o meke this <br /> soil or bedrock?" Yes No deCennlnadfon. <br /> Airy`no'anaws�r ti�dlcsbs Ni.t ths s'►a�b�m is f9�il/ng 1�pro1�.'t <br /> �� <br /> Certffication <br /> This Torm Is to be campleted and etteched to the Summary Fortn Of the Mlnnesute Pollution Control Apenq's(MPCA)Complisnoe <br /> Inspectlon Form Mr E�clating Subaurfiace S�wage Treatrnerrt Systsms.Observe�ons, iMerpratations, and condueions must be <br /> completed by an inspedor or designer.Completed form must be suhmitted to the local unit oi govemment within 15 dsys_ <br /> Property owner name(s): Carlton Hegberg <br /> Property address: 3495 Christi�e Drfire,Orono,MN 55359 ,,, „w <br /> Property owners address(if d�fsrenU: ---�, <br /> Courn�r: Henne�i,n Phone: 612-380-8118 <br /> !here9y oe►tilS+tflat/personeNy mede the observations, int�rpretetions, and concluslons reported on this form end thet�hey e►e <br /> cbI►ecr <br /> Name: Joseph J.Oleon Certification�umber: 1256 <br /> Buslnese Ilcense name and numbe�: Rushr Olson's soil and percu{ation beetlng Llc�810 or <br /> Name of loc�)unit of ganremment= Cih ot Orono <br /> ��; Date; 2115110 <br /> woq-wwTsts4-31 • Compliance Ira,pectfon Form for Exlstfng SSTS <br />