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Parcel number. 27-118-23-44-0007 System status: ❑Compliant �Noncompliant (as detemrined by this fom►) Soil Separation Compliance and Other Compiiance Compliance issue#3 of 4 Date of observation: 6126/9 Reason for observation: City update oroqram This infom►atan on this form does not expire. Compliance questlons/criteria: (Required) Verification Method"':(optional) (Check the a io riate box (Check the appropriafe box) For systems buiit prior to Aprif 1,1996,and not � Conducted soil observation(s)(attach bora�g logs) located in Shoreland or Wel9iead Protection Area or not serving a food,beverage or ❑ Two previous verifications(allad�boring logs) lodging establishment: ❑ Other. Does the system have at least a two-foot vertical separatan distance from periodically saturated soil or bedrock? Yes No For nw►-perfprmance systems buik Aprit 1, 1996,or later or for non-pertormance systems Soi1 observation does not expire.Previous observations located in Shorefand or WN�ead ProtecGon by two independent parties are sufficient,unless site Areas or serving a food,beverage or lodging ��have b�n aliered. establishment: Does the system have a three foot vertical separation distance from periodicaHy saturated soil or bedrodcr ❑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. 70802400): "No standard protocol exists. This list is not exhaustive. Does the system meet the designed vefical in sequential order,nor does k indicate which separation distance from periodicaAy saturated combinations are necessary to make this soil or bedrock?` ❑Yes ❑No determinatrort. Any"no"answer Indkates that the sysbem is failireg to p�olect ground water. Certification This form is to be completed and attached to the Summary Form of the Minnesota Potlution Corrtrol Agency's(MPCA)Complianee Inspection Form for Existing Subsur[ace Sewage Treatment Systems.Observations,interpretations,and conclusions must be completed by an inspector or designer.Completed form must be submitted to the local unit of govemment within 15 days. Ptoperty owner name(s): RICHARD W.PERKINS __ Property address: 1699 NORTH FARM RD-ORONO property owner's address(it different): County: HENNEPIN P��= /hereby certify Hrat 1 personafly made the observations,interpretatans,and condusions reported on this form and that they are co�ct Name: Mark J Hayes Certification number. R5013 Business license name and nuln�er: Minnesota Geotechnical Services,LLC MPCA#L3203 or Na►ne of local unit of govemrt}qnt: Wright County S��: M�,�� Date: 7N 2/9 wq-wwlsts4-31 Compliante Inspectiai Foim for Facisting SSTS 4/4/08