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Parcel number: 0411723340008 System status: �Compliant ❑ Noncompliant (as determined by this fonn) Soil Separation Compliance and Other Compliance Compliance Issue #3 of 4 Date of observation: 10/11/2010 Reason for observation: Property Transfer This infom►ation on this form does not expire. Compliance questionslcriteria: (Required) Verification Method'"`: (Optional) (Check the appropriate box) (Check the appropriate box) For systems built prior to April 1, 1996,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 separafion distance ftom periodically saturated soil or bedrock? ❑Yes ❑ No For non-performance systems built April 1, 1996,or later or for non-performance systems located in Shoreland or Wellhead Protection Soil observation does not expire. Previous observations Areas or serving a food, beverage or lodging by two independent pafies are sufficient,unless site establishment: conditions have been altered. I Does the system have a three-foot vertical separation distance from periodiqlly saturated soil or bedrock?* �Yes ❑ No For reduced separation distance systems(i.e., "perFormance"systems under old 7080.0179 or ' May be reduced by up to 15 percent if allowed in local Type IV or V system under new 7080.2350 or ordinance. 7080.2400): "No standard protoco!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 ❑ No detem►ination. Any"no"answer indicates fhat the system is failfng!o probect ground water. Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compliance Inspection Form for Existing SubsurFace Sewage Treatment Systems.Observations, interpretations, and condusions must be completed by an inspector or designer.Completed form must be submitted to the local unit of govemment within 15 days. Property owner name(s): Chistopher Smith Property address: 2943 Farview Lane,Orono,MN 55356 Property owners address(if different): County: Hennepin Phone: 952-404-3337 1 hereby cerfify that 1 personally made the obseiva6ons, interpretations, and conclusions reported on this form and that they are comect. Name: Joseph J.Olson Certifiqtion number: 1255 Business license name and number: Rusty Olson's soil and perculation testing Lic#810 or Name of local unit vemment: Ciry of Orono Signature: Date: 10/112010 wq-wwists4-31 Compfiance Inspection Form for Existing SSTS 4/4/08