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07/18/2610 00: 03 9527586278 ADVANCED ONSITE INC PAGE 06 <br /> ••Parcel number: System status' 123 Compliant ❑ Noncompliant <br /> (as determined by this form) <br /> Soil Separation Compliance and Other Compliance - Compliance Inspection Form for Existing SSTS <br /> Compliance Issue #3 of 4 <br /> Date of observation: July 12, 2010 Reason for observation: Property Transfer <br /> This information on this form does not expire. <br /> Compliance questions/criteria: (Required) Verification Method": (Optional) <br /> (Check the appropriate box) - (Check the appropriate box) <br /> For systems built prior to April 1, 1996, and not ® Conducted soil observation(s) (attach boring logs) <br /> located in Shoreland or Wellhead Protection <br /> Area or not serving a food, beverage or ❑ Two previous Verifications(attach boring logs) <br /> lodging establishment: ❑ Other: <br /> Does the system nave at least a two-foot <br /> vertical separation distance from periodically — <br /> saturated soil or bedrock? ❑Yes ❑ No <br /> For non-performance systems built April 1, <br /> 1996,or later or for non-performance systems Soil observation does not expire. Previous observations <br /> located in Shoreland or Wellhead Protection by two inoependent parties are sufficient,unless site <br /> Areas or serving a food, beverage or lodging conditions have been altered. <br /> establishment: <br /> Does the system have a three-foot vertical <br /> separation distance from periodically saturated <br /> soil or bedrock?* ® Yes ❑ No <br /> For reduced separation distance systems(i.e., <br /> "performance"systems under old 7080.0179 or • Maybe reduced by up to 15 percent if allowed in local Type IV or V system under new 7080.2360 or ordinance. <br /> 7080.2400): "No standard protocol exists. This list is not exhaustive, <br /> Does the system meet the designed vertical in sequential order, nor does it indicate which <br /> separation distance from periodically saturated combinations am necessary to make this <br /> soil or bedrock?* • Yes 0 No determination. <br /> Any"no"answer indicates that the system is failing to protect <br /> ground water. <br /> Certification <br /> This form ie to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compliance <br /> Inspection Form for Existing Subsurface Sewage Treatment Systems.Observations, interpretations, and conclusions must be <br /> completed by an inspector or designer. Completed form must be submitted to the local unit of government within 15 days. <br /> Property owner name(s): Estate of Diana Gross (Attn: Rich Gross) <br /> Property address: 55 Wear Lane North Orono. MN 5535A <br /> Property owner's address (if different): (Attn:Rlch)721 Bridal Path Trail Hamel, MN. 55340 <br /> County: I lennepin Property owner phone: Rich; (612)866-8608 <br /> I hereby certify that I personally made the observations, Interpretations, and conclusions reported on this form and that they are <br /> correct. <br /> deName; Thomas Kranchnik Certification number R 5945 <br /> Business license name and .-biir: Advanced OnSite, Inc. L 2656 or <br /> Name of local unit of•ov: me • j <br /> Signature: .' Ala Date: July 17,2010 <br /> www.pca.state.mn.us • 651.296.6300 • 800.657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats , <br />