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Rug�09 ��8 01 : 13p Rndy Kleindl [9521 -442-9281 p. 5 <br /> . • <br /> Parcel num r: System status: �]Compliant ❑ Noncompliant <br /> (as determined by this form) <br /> Soil Sep ration Compliance and Other Compiiance <br /> Complia ce Issue #3 of 4 <br /> Date of obs rvation: �Q�_ Reason for observation: Q��y►�ji' y`�1,�� <br /> This informa ion on fhis form does nof expire. <br /> Complian e questionslcriteria: (Requi�ed) Verification Method": (optional) <br /> Check th a ro riate box (Check the appropriate box) <br /> For systems built prior to April 1, 1996,and not �Conducted soil observation(s) (attach boring logs) <br /> located in S oreland or Wellhead Protection <br /> Area or not erving a food, beverage or ❑ Two previous verifications(aitach boring lags) <br /> lodging esta lishment: ❑ Other: <br /> Does the sy tem have at least a two-foot � <br /> vertical sep ration distance from periodically <br /> saturated so I or bedrock? ❑Yes ❑ No _.___ <br /> For non-pe rmance systems built April 1, _ <br /> 1996,or late or for non-performance systems Soil observation does not expire. Previous observations <br /> located in S oreland or Wellhead Protection by two independent parties are sufficient, unless site <br /> Areas or se ing a food, beverage or lodging conditions have been altered. <br /> establishme t: <br /> Does the sy tem have a three-foot vertical � <br /> separation d stance from periodically saturated <br /> soil or bedro k?' Yes ❑ No <br /> For reduced separation distance systems (i.e., <br /> "performanc "systems unde�old 7080.0179 or " May be reduced by up to 15 percenf if allowed in/oca! <br /> Type IV or system under new 7080.2350 or orrlinance. <br /> 7080.2400): ••No standard protocol exists. This list is nof exhaus6ve, <br /> Does the sy em meet the designed vertical in sequential order, nor does if indicafe which <br /> separation d stance from periodically saturated combinations a�necessary to make this <br /> soil or bedro k?' ❑Yes ❑ No determination. <br /> Any"no"an wer indicates that the sysfem is failing fo protect <br /> ground wa <br /> Certifica ion <br /> This form is o be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compliance <br /> Inspection orm for Existing Subsurface Sewage Treatment Systems. Observations,interpretations, and conclusions must be <br /> completed b an inspector or designer. Completed form must be submitted to the local unit of govemment within 15 days. <br /> Properry ow er name(s): Dean Patterson .. __ ..... .. <br /> Property ad ress: 2058 Shoreline Orive _ , ... .._ <br /> Property ow ers address(if different): _ <br /> Counry: enne in Phone: 612-328-1173 <br /> I hereby ce 'fy that!personalfy made the observafions, interpretations, and conclusions�ported an this form and that they are <br /> correct. <br /> Name: A drew Kleindl Certification number: 2926 . <br /> Business lic nse name and number: Jim's Excavatinq, LLC __ or <br /> Name of loc I unit of government: — <br /> Signature: Date: ���d� _ ,. <br /> wq-wwists4- 1 Comp(iance lnspection Form for Existing SSTS <br />