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03/�02/20 17:52 7634988290 � RUSTVS PERC TESTING PAGE 05 <br /> i <br /> I � <br /> � i nt Noncom liant <br /> peroel numqer. 041 1 7231 3001 4 ,. ' . Syatem status: �Compl s ❑ p <br /> � � (as dete►mined by this fo►m) <br /> Soll Separatlon CQ�+npll�nce and Othar Compllance <br /> i <br /> Compliance Issue � of 4 <br /> Date of observation: 1/2011 , Reason for obs�rvation: P�rtY T►ansfer _, ,_ ., <br /> This informa8on on this fiorm does not exp;re. <br /> ' Co�plian�e questlons/criter�a; (Required) VeNflcatio�Method"': (Optionaq <br /> __�heck the aPAroPriate box _._ (Clreck the approp►iate box) <br /> For�ystems built pnor to April�and no� � Conducted soil observation(s)(attach boring logs) <br /> �in Shoreland or Wellh�d Protection <br /> ArBa or not serving a food, beverage or ❑ Two previous verifcatlons(atlach bo�ing(ogs) <br /> fodging eetablishment: I ❑ Other: W _ ... , --- <br /> Does the system have at leest a two-toot <br /> ' vertica!s�paration distance fivm periodic�lly -, :: ".�— '.— <br /> saturated soil or bedrock? _,ry ,...,, Yes No <br /> ��'" _ . — <br /> Far non-performe�ce systems built April 1, , _ ,.__. _,— <br /> 1996,o�later or for nnn-pertormance systems <br /> located in Shoreland or Wellhead Protectlon Soil observetion does not expire. P�evious observ�tions <br /> Areae or serving a food, beverage or lodging by two independent parties are suflicient, unless site <br /> establishment: conditions have been altered. <br /> Does tlie sy have a threo-foot vertical <br /> sepa 'on di ce from periodically saturated <br /> _soil or , �Yes ❑No_- <br /> For ced ration distanoe systems(i.e.,� <br /> "perFo ance" ystems under old 7080.0179 or ` May be reduced by up tn 15 parcenf If e/lowed in local <br /> 7ype IV or V s stem under new 7080. Z350 ar o►dinance. <br /> 7080.2400): •*No stand�rd protocol exists. Thls list is not ezheus6ve, <br /> Does the syst mget the designed ve�tical in sequential order, nor doss i�lndicete which <br /> seperation dis noe from periodically saturated combinations ere rrecessary to make this <br /> so or bedro ' ❑Yeg ❑ No detem►inetion. <br /> Any"�ro"sns indlce[as that the sy$loem is 1�11l►►�t�prvt�ct T <br /> grpund wabrr. <br /> � <br /> Certific tion ! <br /> This form i o be completed and attached to the�mmary Form of the Minnesota Pollution Control Agency's(MPCA)Compliance <br /> Inspectio onn for E:EsUng�Rub�urface S�Treatrnerrt 8yatems.Observations,interpretations, and conc9usions must be <br /> wmplated by an i�spedor or d signer. Compl frnm must be aubmitted to ihe local unit of govemme�t within 15 days. <br /> I <br /> Properly �neme(s): _ � M Post.. _ <br /> Property address: 2755 Deer Run Trail_East, Orono, MN 55356,__ <br /> � Pro�rty ner's eddress(if d�ferent)� �.__ <br /> Caunty: Henne in _,, Phone: _812-747-0263 _ <br /> 1 he�by c� ' that�personalty made the obse►vadons, interpreFa6ons, and condusions►epolt9d on this lonn and that they a►e <br /> comect. <br /> Name: Joseph J.Olson N„_,,,_, ._ Ce�tification number: 1255 <br /> Business lioense name e�d number: Rusiy Olson's soil end�,rwlation testfng Lic#81� .. or <br /> Name of local uni f ovemment: City of Orono „_ ,_ _„ „ _._____ <br /> -._... �.. _ .. <br /> : ,_....... <br /> Signature: ' Date� 3J2/11 <br /> _..._....— _....._ .,.........---- � <br /> � I <br /> . .- -.-.-�-�-. +. rn.�nlinn�o Inenortinn enrm fnr Frfellno.SSTS <br />