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02/0612009 10:19 7634275934 SYSTEM SOLUTIONS PAGE 05 Parcel number. _ System status: /Compliant [3Noncompliant (as determinedthis form) Soil Separation Compliance and Other Compliance Compliance Issue #3 of 4 Date of observation: �jdReason for observation: -- This information on thisform o not expire.' Compliance questfons/criteria: (Required) Verification Method'-•(Optional) (Checkthe appm nate box (Check the approprfete box) For systems built prior to April 1, 1996,and not [I Conducted soil observation(s)(attach boring logs) located in Shoreland or Wellhead Protection Area or not serving a food,beverage or ❑ Two previous verifications(alta h boring logs) lodging establishment: Other: 1 (��` Does the system have at least a two-foot, vertical separation distance from periodically T�— saturated soil or bedrock? Yes, No For non-performance systems built April t, 1996,or later or for non-performsnce systems Soil observation does not expire. Previous observations located In•Shoreland or Wellhead Protection by two Independent parties ani sufficient,unless.sile . Areas or serving a food,beverage or lodging conditions have been altered. establishment: 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., * Mey be reduced by up to 15 percent if allowed in local "performanps"systems under old 7080.0179 or ordinance. Type IV or V system under new 7080.2350 or 7080.2400):• '*No standard protocol exists. This list is not exhaustive, Does the system meet the designed verticalin sequential order, nor does it indicate which separation distance from periodically saturated 'combinations are necessetyto make this _soil dr bedrock?* Yes QNo dete'rm/nation. Any"no"answer,Indicates that the system/s falling to protect ground water. Certification, This form*Is to be'completed and attached to the Summery Form of the Minnesota Pollution Control Agency's(MPCA)Compliance Inspection Form for Existing Subsurface Sewage Treatment Systeme.Observations,Interpretations,and conclusions must be completed by an inspector or designer.Completed form must be.submitted lo.the local unit of government within 15 days. Property owner name(s): C if Property address: Property owner's address(if dmf rent): l County: Phone: 1 hereby certify that i personally made the.observations, interpretations, and conclusions reported on this form and thief they am correct. VIC HAGENAH Phone: 763,427,593 Name: ' SYSTEM SOLUTIONS.�15231 Jackel St. N Business license name and number. MPCA#1483 Ramsey, MN 55303 Name of local unit ofg• mment: Signature: Date: