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05/25/2010 10:40 7634988290 RUSTVS PERC TESTING PAGE 05 <br /> Parcel number, 3311623430017 System stetus: � Complient ❑ Noncompliant <br /> (es determined by this form) <br /> Soll Separation Compllance snd Other Compllance <br /> Compliance Issue #3 of 4 <br /> Dete of observation: 5/19/10 Reason for obaervetian: Property Transfer _, _ <br /> Thls lnfnmretion on this form does not exp;re. <br /> Compliance questlons/crlteria: (Required) Veriflcatlon Method": (optional) <br /> (Check the app�opriate twxL_w__ (Check the app►op�ate box) <br /> Fvr systems built prior to April 1, 1986, end not � ConduCted soil observalion(s)(attach boring logs) <br /> focated in Shoreland o�Wellhead Protection <br /> Area or not ssrving a faod,beverage or ❑ Twv previous verific�tions(attach bo�ing loge) <br /> lodging establlshment: ❑ Other; ._ <br /> Dves the system have at least a two-foot <br /> vertical separation dlsfsnce from periodically ' <br /> saturated soil or bedrock? ❑Yes No ----„ <br /> For non-performance sys/ems built Apnl 1, <br /> 1996,or later or for nun-pertormenoe systems <br /> Soil observatlon does no � <br /> located in Shoreland or Wellh�d Protection t expire. Prevlous observations <br /> Areas or servi�g a food,beverege or lodging by two independent perties are sufficient, unless sile <br /> esteblishment: condltlane heve been altered. <br /> Qoes the syst�m heve a three-foot veRlcal <br /> separ�tfon dlstsnce from periodicelly setureted <br /> soil or bedrock?` Yea No <br /> For reduced separatfon distance systems(i_e., <br /> "performsnoa'systems undar old 7080.0179 or ' May be r�educed by up to 15 percent if allowed in local <br /> Type IV or V system under new 7Q80_2350 or ordinance. <br /> 7Q802400): "No standerd protocol exists. This list is nat ezheustive, <br /> Does the eystem meet the designed vertical In sequen6e/order, nor does it indicete whlch <br /> separation distance from periodically saturated com6ina6ons are►�ecessery to make this <br /> soil or bedrocic?` Yes ❑ No defem'dnetion. <br /> Any"no"snswer lndicaOss thet the system!s fa/l/ng t�o p►ot�ct <br /> ground waear. <br /> Certification <br /> This form is to be completed and attached to the Summery Form of the Minnesota Potlution Control Agency's(MPCA)Compliancs <br /> InspecGon Fonn for Existing 8ubsurface Sewags TreatmeM Systems.Observstions,lnterpretations, end condusions must be <br /> completed by�n inspector or deslgner. Gompleted form must be submitted to the locel unit of govemment within 15 days. <br /> Property owner�ame(s)� Kenneth Zagzebskl <br /> Property eddress: _27Q0 Copperview Drive,_Orono�MN 55356 _ _ <br /> Property owner's address(IP di1►erorm: <br /> County: Hennepin Phone: 612-203-8473 ,, � <br /> I he►eby ceKlry that 1 personally mede the observatfons, inferpr+statfons, arrd conduslans reported on this form and thet they a�e <br /> correct. <br /> Name: Joseph J.Olson Certification number_ 1255 _ <br /> 8usiness license name and number: Rust�(Olson's soil and perculstion testin�L.ic#610 0► <br /> Name of local unil of overnment: City of Orono �,�,,,,,,,,,_._ <br /> Signature: Dete_ S25J10 <br /> wq-wwists9•31 Compllarrce Inspection Form for Existing 55TS <br />