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OCT, 22, 2009 2: 27PM Edina Realty Wayzata—RR3 N0. 3565 P, 3 ParCel number: _ System status: Compliant � Noncornpliant (as determined y his form) Hydraulic Performance and Other Compliance Compliance Issue #1 of 4 ' Date of observatior: - -OQ Reeson for Observation: ,_� , This form expires u pon next inspection or ict three years,whichever occurs firs� Compliance questions/criteria; (Required) V�rification Method": (Optional) (Check Nre ap�'� riafe box � (Check the appropriate box) Does the system di scharge sewage to the ❑Yes No qround surface? �Searched For surface outlet � Performed hydrsullc test Ooe$the system di scharge sewage to drain ❑Yes I�lo tile or su�ace watei�? �Searched for seeping in yard Does the system c��se sewage backup ❑Yes �lo �hecked fo�backup in home into dwelling or es�,blishment7 ❑ ��sive ponding in soil system/�-boxes Do other situations �acist that have the . ❑Yes �No potential to immedis itely and adversely ❑ Homeowner testimony impact vr threaten F�ublic health or s�fety �Examined for surging in tenk Selectrical,unsafe c�vers etc_� Any"yes"answer/�d�cates that the syslem!s an lmminent ❑ "B�ack soil"above soil dispe�sai system threat to public hea ith and safety. ❑ System requires"emergency'pumping Does the system po�e a threat to ground ❑Y�s No � Pe�O�"ed dye test . water for any canditi ans deemed non- ❑ �her: �j 1 � 1 S SD��1b(11�_ protective as detem ined b the ins ecto�? lt0� D� �MDU�� l�T UVt(� �._. "Y�.s"lndicates th�t the syster»!s failJng to protect � ,�p-�- 1��,(�q , ground water.If"y es'; descrlbe the condifion noted: � '" ' " 'No standardprotocal exist�is not exha�stive, in sequantial order, nor does it indicate which combinafions ar�e necessary to make ihis determinerion. Cer�ification This form is to be cc mpleted and attached to tfie Summary Form of the Minnesota Pollution Control/�qency's(MPCA)Compliance Inspection Form fc�Existing Subsurtace Sewage Trsatment Systems.Observations,interpretations, and conclusions must bs completed by an ins�ector.Completed form must be submitted to the local unit of government wlthln 15 days. Property owner narr e(s): v`� � .S PropeRy address: � Property owner's ad�ress(if dif�ersnt): County: ��(J►ti.- Phone: _,�, 1 hereby certlfy that,personally made the observetions, interpretations,end conclusions rsported on this form and thaf they are correct. Neme: �� i 9p��9r Certification number: ��(p� �� . 8usiness license na►ne and numbsr. � or Name of local ' 01 g emm � Signature: ' D te: �^ �4-�.W __ __ a wq-wwists4•31 Compliance �nsvecrion Form fo�Erlsrina SSTS