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OCT. 22 2009 2:27PM Edina Realty Wayzata—RR3 N0, 3565 P. 6 , Parcel nu ber. ___ System stetus:�ompliant ❑ Noncompliant (as determined y this form) Soil S awation Compliance and Other Compliance Compli nce Iss�,e #3 of 4 � Date of o ervation: �— �Q — ��Reason for observation: � This lnfor ation cn t�ys form does not expire. Complia ce questions/criteria: (Required) Verification Method�"': (Optional) Check e s ro i'iate box (Check the approprlate box) For syste s built prio•to April 1, 1996, and not �CondUcted soil observation(s)(attech boring logs) located In horeland �r Wellhead ProteCtion Area or n serving a foad,beverage or ❑ Two previous verifications(attach boring Iogs) lodging est�blishmen: ❑ Other. 1" 13�� 119 �'� �� a� Does the�ystem haw�at least a two-foot _ $•� � -- ' u� vertical separation die tance from periodically saturated soil or bedn►dc? Yes No _�,�(�_ ��' `` For non-performance systems bulltApril.1, 1996,or later or for nc m-perFormance systems Soil observation does not e ire.Previous obsarvations located in Shoreland��r Wellhead Protectio� rva xp Areas or serving a foc�l,beverage or(odging by two independent parties are su�clent,unless site esbblishment: conditivns have been altered. Does the s stem havE�a three-foot vertiCal separallon istance ir�m periodically saturated soil or bed ck?' Yes No For r�duc separatic n distance systems(i.e., "perf�rtnan e"system s under old 7080.0179 or " May be reduced by up to i5 percent rf allowed in local � 7ype IV or Y system �nder new 7060.2350 nr ordinance. 7080.2400� '�No standard protocol exists. This list is no�exhaustive, I Do�s ths system mes;the designed ve�tical in sequential order,nordoes it indicate which separation istance fn�m periodically saturated combinations are necessary to make rhis soif or bed ck?' Yes No determina�on. Any"no"a swer indl�:ates that the system►s failing!o protect grcund wa r. � Certific tion ' ��_,—__ . This form 1 to be completed and attached tv the Summary Form ofthe Minnesota Pollution Control/�,qency'g(MPCA)Compliance Ihspection Fomn for;xisting Subsu�Face Sewage Treatment Systems.Observetions,intecprebtions,a�d conc►usions must be compieted y an inspF ctor or designer.Completed form must be submitted to the local unit of govemment withi� 15 days. Property o ner namels): �(Jh 7 , 11/�� "__ _� _ _ Property a�ress: J�� /'kdCfiQ,. e � Property o ner's addr:ss(if diffeerent): �, � — -- Coun '(�� Phone: I he�by ce ify that 1 p sr�onally made the observatlons,Interpretations,and conclusions reported on thls form and that they are COR@Cf. , Name: \ ° �j�1CJ Certification number. �11p��i Business li nse namE�and number. � ��C �d�C, c�f'� or Neme of lo I unit of g�v e � Si9nature: Oate: � 3d� O�__ _ � wq-wwlscs4 31 Compliance Insoection Fo�m fo�Existina SSTS