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Parcel number: 2611823320012 System status: ®Compliant ❑Noncompliant (as determined by this fort) Hydraulic Performance and Other Compliance Compliance Issue#1 of 4 Date of observation: 10/06/10 Reason for observation: Property Transfer This far expires upon next inspection or in three years,whit hem occurs first 10/06/13 Compliance questionelcriteria: (Required) Verification Method': (Optional) Check the appMpnate box (Check the appropriate box) Does the system discharge sewage to the ❑Yes ®No ® Searched for surface outlet round surface? Does the system discharge sewage to drain ❑Yes ®No ❑ Performed hydraulic test file or surface waters? ® Searched for seeping in yard Does the system cause sewage backup ❑Yes ®No ® Checked for backup in home into dwellingor establishment? ❑ Excessive ponding in soil system/l)-boxes Do other situations exist that have the ❑Yes ®No ❑ Homeowner testimony potential to immediately and adversely impact or threaten public health or safety ❑ Examined for surging in tank electrical,unsafe covers,etc.)? ❑ `Black soil'above soil dispersal system Any"yes-answer indk otes that the system is an imminent threat to public health and safety. ❑ System requires"emergency"pumping ❑ Performed dye test Does the system pose a threat to grand ❑Yes ®No ❑ Other waw fa'any corm deemed non- protective determined bythe Wes-indicates that the systema failing to protect ground watt.If"yes';describe the condition noted: *No standard protocol exists. This list is not exhaustive, in sequential order,nor does it indicate which combinations are necessary to make this detemdnation. Cert fication This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compliance Inspection Form for Existing Subsurrface Sewage Treatment Systems_Observations.irrtdarpretations,and conclusions must be completed by an inspector Completed form must be submitted to the local unit of government within 15 days. Property owner name(s): Daniel&Rebecca Bolgar Property address: 1560 Tanglewood Road Orono,MN 55356 Property owner's address(if different): County: Hennepin Phone: 952-476-0676 1 hereby certify that I personally made the observations,k9erpretalions,and conciumons reported on this form and that they are corect Name: Joseph J Olson Certification number: 1255 Business ficanw name and number: Rusty Otsat's soil and perc ulation Ming Lie#810 or Name of local unit of government City of Orono Signature: Date: 10/09/10 wq-wwists4-31 Compliance Inspection Form for Existing IM 414108