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Parcel number. 27-118-2�31-0021 _ System status: �Compiiant ❑ Noncompliant <br /> • (as determined by this form} <br /> S�ii Separation Compliance and Other Cvmpliance - Gompliance�nspection Form forExistirtg SS�S <br /> CompEiance lssue #3 of 4 <br /> Date of observation 3-29-11 Reason for observation: transfer of tifle <br /> This informa6on an thrs form does not expi�. <br /> Campliance questions/criteria: {Required) Verificatian Method"*: (Dptionaq <br /> (Check the appro riate box <br /> r- (Check the approprrate box) <br /> For systems built prior to Apri1 1, 1996, and not '' � Conducted soil observation(s} (attach boring fogs) <br /> ior�ted in Shorefand or Welihead Protection <br /> Area ar not serving a food, beverage or ❑ Two previous verifications(attach bonng fogs) <br /> lodging establishment: ❑ Other. <br /> Does the system have at least a iwo-foot <br /> vertica!separation distance from periodically <br /> saturated soi{or bedrock?_�_ j ❑Yes ❑ No <br /> �or rron-performance sysfems buiff April 1, <br /> 1996, or later or for non-pertormance systems - <br /> Iocated in Shorefand ar We(ihead Protection ' Soil observation does not expite. Previous observatior�s <br /> Araas or serving a food, beverage or}odging ; by two independent parties are sufficient, unless sife <br /> estabiishment ! conditiorrs have been a4tered. <br /> Does the system have a three-foot verticaf � <br /> separation distance from periodically saturated ; <br /> _ soil or bedrock?_,_ j �Yes ❑ No <br /> For reducsd separ�van c}isfance sysfems(i.e., i <br /> `peRormance"systems under old 7080.0179 or ; ' May be r�duced by up to 15 per�ent if alfowed in loca! <br /> Type IV or V sysfem under new 7080.2350 0; ' or�inance. <br /> 7680.2400): ' "No standard protocol exisfs Thrs Gst rs not exnattstive, <br /> i7oes+.he s��ster,�meet the designed veri;cal , in sequsnfia!orr�er,nor does it inBicate which <br /> separation distance from periodicaily saturated corrrbinations are necessary to make this <br /> soil or bedrock7` I ❑ Yes ❑ No determination. <br /> Rny"na"answer inclicafes fhat the system is failrng to profect <br /> ground water. <br /> Eertifcation � <br /> This form is to be compieted and attached to the Summary Form of fhe Minnesota Pollution Controi Agenc}�s (MPCA) Camptiarsce <br /> [rsspection Farm for Existing SubsurFace Sewage Treatrrterrt Systems.Observations, irrterpretations, and conc!usions must be <br /> completed by an inspeefo;or designer. Completed form must be submitted to the locai unit of govemment within 15 days. <br /> Prope�ty owner rame(s}: <br /> Properly address: '!'�20 Cox Farm Road,Orono MN 55356 <br /> Property ownei's address(if drftererrt): <br /> Gounty: Hennepin Praperty owner phone: <br /> !hereby certify that!personally made the observations, interpretations, and conclusions r�ported on thrs forr,•r and that they ara <br /> corr�ct <br /> Name: Pemel Hent es _ Certificatian numf�er. 2Q64 <br /> Business ficense nam number. Chip's Septic Service LLC or <br /> Name of iocal urrit of vemme � <br /> Signature: __ — -- - - Da�e: 7-2'i-11 <br /> wH�w_pca.state.mn.us - 65i-29b-6300 • 800-657-3$64 • T'f"Y 65i-282-533Z or 800-557-3$64 • Avaita6le in attemative formats <br /> wq-wwjsts4-31 • 4/Z4/09 „ <br />