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OCT -22 2009 2:27PM Edina Realty Wayzata—RR3 N0,3565 P. 6 Parcel nui riber System status.ompliant (I Noncompliant (as determined y this form) Soil Separation Compliance and Other Compliance Compli nce lsslrte #3 of 4 Date of o ervation: I — 10 ! 01 Reason for observation: This infor ation on tt is form does not expire. Compllaf ,ce questionsleriteria: (Required) For syste s built prlo r to April 1, 1986, and not located In horeland )r Wellhead Protection Area or serving a food, beverage or lodging esteblsshmen : Does the gystem haw t at least a two -foot vertical separation die tance from periodically saturated soil_ or bedn )dc? For non-performance systems built April .1, 1996, or later or for non-performance systems located in Shoreland or Wellhead Protection Areas or serving a foc d, beverage or lodging establishment: Does the s'stem havt - a three-foot vertical separationdistance fr rn periodically saturated For reducseparatic n distance systems (i.e., "perbrman e" system s under old 7080.0172 or Type IV or Y system L )ider new 7080.2350 or Does the system mes: the designed vertical separation instance farm periodically saturated Any "no" aer wer indl rates that the system is falling to project ground wa Verification Method**: (optional) (Check the appropriate box) Conducted soil observatlon(s) (attach boring logs) ❑ Two previous verifications (attach boring logs) ❑ Other:'�e�L1� 1��3Q�" 1� _ 1. b &` It Soil observation does not expire. Previous observations by two independent parties are sufficient, unless site conditions have been altered. * May be reduced by up to 15 percent if allowed In local ordinance. No standard protocol exists. This list is not exhaustive, In sequential order, nor does it indicate which combinations are necessary to make this determination, Certific tion This form Is to be oom plated and attached to the Summary Form of the Minnesota Pollution Control Agency's- (MPGA) Compliance Inspection Form for 1xisting Subsurface Sauvage Treatment Systerns. Observations, tntorpretations, and conclusions must be completed I iy an lnsp4 ctor or designer. Completed form must be submitted to the local unit of povemment within 15 clays. Property ov iner name(s): Property address: r:2 LliaC#� Property oo ner's addr ass (if different): County: �� Phone: I hereby eelky that I p sr„onally made the obserratlons, Interpretations, and conciusions reported on this form and that they are correct. II Name: Business tic Dnse namr i and number. Name of local unit of g) Signature: Certification number. t`�1(o5q S lin(, _ _ or Date: wq-W-"SCS9#31 Compilance rnsDacrion Form fDr Existine .ISYS