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Oct 15 09 �08: z0a Rndy & Julie Kleindl [9521 -442-9281 p. 5 ' I Parcel nurnp er: System status: ,� Compliant ❑iVoncompliant I (as determined by this iorm) Soil SeRaration Compliance and Other Compliance Complia�ce Issue #3 of 4 Date of obs�rvation: �O-'�-�� Reason for observation: ____�rd p��-� T��a%� This inform�tion on this form does nof expire. Complianj�e questionslcriteria: (Required) Verificafion Method'*: (Optionaq (Check the appiaeriate box (Check fhe appropriate 6ox) For system�built prior to April 1, 1996, and not ,@� Conducted soil observation(s)(attach boring logs) located in S�horeland or Wellhead Protection Area or not�Serving a food,beverage or ❑ Two previous verifications(attach boring logs) lodging es blishment: ❑ Other: Does the s}�stem have at least a two-foot ; vertical sep ration distance from periodically saturated s il or bedrock? ❑Yes ❑ No For non-per�ormance systems builtApril 1, 1996,or latgr or for non-performance systems �'— located in S�oreland or Wellhead Protection Soil observation does not expire.Previous observa6ons Areas or se mg a food,beverage or lodging by two independenE parties are sufficie�t, unless site establishm�t: conditions have been altered. Does the sy�stem have a three-foot vertiql separation �istance from periodically saturated j soil or bedr ek?` i Yes ❑ No For reduce separation distance systems(i.e., "performan "systems under old 7080.0179 or ' May be r�duced by up to 15 per�ent if allowed in local Type IV or system under new 7080. 2350 or oidinance. 7080.2400): '•No standard protocol exists. This list is nof exhaus6ve, Does the sy tem meet the designed vertical in sequential order, nor does it indicate wh;ch separation istance from periodically saturated combina6ons are necessary to make this soil or bedr k?' ❑Yes ❑ No determination. Any"no"a swer lndicates that fhe system is failing to protect ground wat r. Certifica ion This form is o be completed and attached to the Summary Form of the Minnesota Pollution Control Agenc�s(MPCA) Compliance Inspection ortn for Existing Subsurface Sewage Treatrnent Systems.Observations,interpretations, and conclusions must be completed an inspector or designer.Completed form must be submitted to the local unit of govemment within 15 days. Property ow er name(s): Property ad ress: 763 Ferndale Road North, Orono MN Property ow ers address(if different): County: enne in Phone: 612-781-2321 l heieby ce ' thaf 1 personally made the obsenrations, infeipr�ta6ons, and conclusrons reported on this form and thaf they are correct. Name: A drew Kleindl Certification number: 2926 Business li nse name and number: Jim's Excavating 8 Pumping, LLC or Name of lo I unit of govemment: Carver Coun _ Signature: Dafe: ��1-`'j��'