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07/18/2011 17:32 7634988299 RUSTVS PERC TESTING PAGE 65 <br /> Parcel number: 3311823330003 _ System stat►is: �ComWiant ❑ Norwompliant <br /> -"..._ •- (es detem�lned by tfiis form) <br /> Soil Soparallon Complla�ce and Other Cot�plla� <br /> Compl9ance Issue !�3 vf 4 <br /> Date of observaCion: 7H 3J11 Reeson for observetion: PropeRy Trensfer <br /> This lnformation on thls form does not explre. <br /> CanpllancQ questionslcrfteria: (Required) VeMNc�tion Method": (Optional) <br /> (Check the epprvpriate box) (Check the appropriat�bax) <br /> For systems bullt p�or to Apri� 1, 1686,and not � Co�duded sofl observation(s)(atte�ch bo�ing logs) <br /> located in Shoreland or Wellhe�d Protec3ion <br /> Mee or not seni�g a food,beverage or ❑ Two previous verifications(etkech boring b8s) <br /> lodging estaWishmeM: ❑ Other _ <br /> Does the system havic ei I�st a 1wo-foot <br /> vertical separ�Uon dietance firom periodlcally " ,. ._ .- — <br /> seturated.soil ar bedrook? ^ Yes No _,. <br /> For non-pe►formance systems built April 1, <br /> 1998,or later or for non-pertormance systema Soil observa�on does not expire. Previous observations <br /> loceted in Sho�eland or Wellhead Protection by t�independent perties are sufTicient, unless site <br /> Areas or aerving a food,beverage or lodginq ap��heve been atter�ed. <br /> establishment: <br /> Doas the system h�v+e a three-foot veRical <br /> separation distance fnom perbdicalty saturated <br /> soil o�bedrodc?' Yes ❑ No „ <br /> For reduc�ed separation distance systems(i.e., <br /> `perFormance"systems under old 7080.0179 or ' Mey be►educed by up to 15 pen;ent/f el/owed in loca/ <br /> Type IV or V system unde�new 7p8D.2350 or onl/nence. <br /> 7080.2400): "'No standarol protocol exists. This list is not exheusdlve, <br /> Doeg the system meet the designed vertical in sequential ortier, rrordoes itlndicet+e whi�h <br /> separation distsnoe from periodically satureted combinetiens eia necessary to make this <br /> soil or bedrocKT` Yes ❑ No �����. <br /> My"no'°anawer indlcatas tbat dre syatem!s fallln�tn praEsct <br /> ground wstar. <br /> Certif9cation <br /> Thia for►n is to be Completed and attached to the Summary Fc►m of the Mlrtnesote Pollution Control Agency's(MPCA)Compliance <br /> In.pectlan Fom�for Exlsting 8ubaurface Sewage 7roatrnent 8ysbems.Observations,irtterpretatio�s, and c�ondusions must be <br /> completed by an inspec�tor or designe�-Completed form must be submitted to tt�e local unk of govemment wfthin 15 days- <br /> Property owner name(s): mDougla6 Reynolds <br /> Property address: 75 C etal Creek Roed Orono, MN 65366 <br /> Property ovmer's address(iFdAterent): „w_ �,_ --. <br /> County: Hennepin __ Phone: 812-32�2570 ,__.,�_,_ m <br /> 1 heieby ceRi/y thet I personally made ihe obseivetions,interp►etations, end oonclusions�eparted on this fv►m and Htat they are <br /> cnr►�t. <br /> Name: Joseph J Olson � Certification number. _1255 . <br /> Business license name end number: Rusty Olsnn's eofl and peoailapon�esdng Lic i�810 _ or <br /> Name of local unit of govemment: City of Orono „ , ...,� <br /> Signature: � _ �,,.,,,� ,,,_ Dete: 7/15/11 --- ,,�- <br /> . <br /> � <br /> wq-wwistsl-3 f Complinnce Inspection Form for Exfscing SSTS <br />