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Parcel number 2611823320012 System status: ®Compliant ❑Noncompliant (as detenWned by this form) Soil Separation Compliance and Other Compliance Compliance Issue#3 of 4 Date of observation: 10/06/10 Reason for observation: Property Transfer This information on this form does not expire. Compliance questions/criteria:(Required) Verification Method'*: (Optional) Check the appropriate box (Check the appropriate box) For systems built prior to April 1.1996,and not ® Conducted soil observatio (s)(attach boring logs) located in Shoreland or Wellhead Protection Area or not serving a food,beverage or ❑ Two previous verifications(attach boring logs) lodging establishment: ❑ Other Does the system have at least a two-foot vertical separation distance from periodically saturated soil or bedrock? D Yes 0 No For non-performance systems built April 1, 1996,or later or for non-performance systems located in Shoreland or Wellhead Protection Soil observation does not expire.Previous observations Areas or serving a food,beverage or lodging by two independent parties are sufficient,unless site establishment: conditions have been altered. Does the system have a three-foot vertical separation distance from periodically saturated soil or bedrock?' Yes No For reduced separation distance systems(i.e., °performance°systems under old 7080.0179 or ` May be reduced by up to 15 percent if allowed in local Type IV or V system under new 7080.2350 or ordinance. 70802400): "Alo standard protocol exists. This list is not exhaustive, Does the system meet the designed vertical in sequential order,nor does it indicate which separation distance from periodically saturated combinations are necessary to make this soil or bedrock?' Yes No determination. Any"no'answer Liar that the system is fatting to protect ground water. Certification This form is to be completed and attached to the Summary Foran of the Minnesota Pollution Control Agency's(MPCA)Compliance Inspection Form for Existing Subsurface Sewage Treatment Systems.Observations,interpretations,and conclusions must be completed by an inspector or designer.Completed form must be submitted to the local unit of government within 15 days. Property owner name(s): Daniel&Rebecca Bolger Property address: 1560 Tanglewood Road,Orono,MN 55356 Property owner's address(d cWer ent): County: Hennepin Phone: 9512-476-0676 1 hereby certify that I personally made the observations,interpretations,and conclusions reported on this form and that they are correct. Name: Joseph J.Olson Certification number. 1255 Business license name and number: Rusty Olson's soil and perculation testing lac#810 or Name of local unit of government City of Orono Signature: Date: 101139/10 wq-ww1sts4-31 Compliance Inspection Form for Existing SSTS 414108