Laserfiche WebLink
Parcel number: _._____,.__._._�_, „� System status; �Compliant ❑Noncompliant <br /> (as determined 6y tl�is form) <br /> Soil Separation Cornpiiance and Other Cort�p�ranae <br /> COmpliance issue #3 of 4 <br /> Date of observation: � Reason for observadvn: Gl (�. _„� <br /> Thfs informatior►on this form does no[expire. <br /> Compliance questivns/criteria: (Required) Verificatfon Method"""': (Optional) <br /> _w Check the ro riate box (Check the appropriate box) <br /> For systsms buflt prior to April 1, 1996, and not �Cond�cted soil observation(s)(attach boring logs) <br /> located in Shoreland or Wellhead Protection <br /> Area or not serving a food,beverage or ❑ Two previous verifications(attach boring logs) <br /> lodging establishment: ❑ Other: �� 1 �� � �-- l-Q 1� <br /> Does the system have at least a 1wo-foot ��.-a-TIl�'�- l��jv�.►t� <br /> vertical separa�cn distance from periodically ,��5 <br /> saturaced soil or bedrock? � Yes No /UD l�7 <br /> For non•perFormance systems builtApril 1, ���� .�.,�..l.�s��4' <br /> 1996,or later or for non-performance systems �il observaGon does not expire,Previous observativns <br /> located in Shor��and or Wellhesd Protection by two independent parties are suificient, unless site <br /> Areas or servinp a food,beverage or lodging conditions have been altered. <br /> establishment; <br /> Does the system have a three-foot vertical <br /> separation distance trom periodically saturatod <br /> _sail or bedrock?�, Yes ❑ No <br /> For reduced separation distance systems(i.e., <br /> perfortnance systems under old 7080.0178 or ' �ay be reduced by up ta 15 percent if allowed in loc�! <br /> „ „ <br /> 7ype IV or V system under new 7080. 2350 or ordinance, <br /> 7080.2400): ••No standard protocof exists. This list is not exhausGve, <br /> Does the system meet the designed vertical in sequentia!order, nor does it indicate which <br /> separacion distance from periodically saturated combinatrons are necessary to make this <br /> soil or bedrock?' „ � ❑Yes No defermination. <br /> Any"no"answer indicates Lhat the system!S failing to protecf <br /> ground water. <br /> Certification � <br /> This form is to be completed and attached to the Summary Fo►m af the Minnesota Pollution Contr�l Agency's(MPCA) Compliance <br /> Inspection Fortn for Existing�SubsurFace Sewage Treatment Systems. Observations, interpretations, ana conclusions must be <br /> completed by a�inspector o�designer.Completed form must be submitted to the local unit of govemment within 15 days. <br /> F � 1 <br /> ProperCy owner name(s); _ l�l b _,. ..,. .. ------•---- �-- - <br /> Property address; ` C� _�,--�-- ----�- -•-- <br /> Propert�r owner's address(if different); ,�,. _ ••� ---• ----� ••• <br /> County; _��� Phone: .v _._.. .- -- �— <br /> 1 hereby cer7�fy fhaf!personally mede the observations, interpretations, and conclusions reported on this form and that they are <br /> c�rreck - <br /> Name; �Q�� �V Certification number: � � ..,__ <br /> Business license name and numbe�, ���i '� 1 . .,,,. �5�- or <br /> Name of local unit o( ern t: _., � -�- � -- -• <br /> Signature; _ . �ate: ,�__,____ ,, ... <br /> wq-wwiscs4•31 Comp(iance Inspection Form fo�Existing SSTS <br /> 4/1/08 <br /> 90fb9 39Gd ZTZEEL8Z96 6Z�bt tt9Z/50/5e <br />