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4 Parcel number. 0411723110022 System status: ®Compliant ❑Noncompliant (as determined by this form) Soil Separation Compliance and Other Compliance Compliance Issue#3 of 4 Date of observation: 10106/10 Reason for observation: Property Transfer This information on this form does not expire. Compliance questions/criteria:(Required) Verlflcatlon Method":(Optional) (Check the appropriate box (Check the appropriate box) For systems built prior to April 1,1998,and not ® Conducted soil observation(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? ❑Yes No For non-performance systems built April 1, 1996,or late or for rram-performance systems located in Shoreland or Wellhead Protection Soil observation does rat expire.Previous observations Areas or serving a food,beverage or lodging by two independent parties are sufficlent,unless site establishment: conditions have been altered. Does the system have a three-foot vertical separation distance from periodically saturated soil or bedrock?' 0 Yes El No For reduced separation distance systems(i.e., 'performance*systems under old 7080.0179 or 'May be reduced by up to 15 percent H allowed in local Type IV or V system under new 7080.2350 or ordinance. 7080.2400): "hyo standar/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 0 No determination. Any no'answer ladYdOrms 6W the syssam is f&Hft to p roled grand wear. Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Contrd Agenc y s(MPGA)Compliance Inspection Form for Existing Subsurface Sewage Treatment Sysiiems.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): Stephen&Katherine Poley Property address: 2605 Thoroughbred Lane,Orono,MN 55356 Property owners address(if different): County: Hennepin Phone: 952-404-1413 1 hereby car*that I personally made the observations,kderprelaffions,and conclusions reported on Bis form and that they are correct. Name: Joseph J.Olson Certification number: 1255 Business license noire and number: Rusty Olson's soil and petaAation testing Lic#810 or Name of local unit o�mment: City of Orono Signature: 4� Date: 10/09/10 wq-ww1sts4-31 Compliance Inspection Form for Existing SS7S 414108