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07/17/2008 94:23 7634975911 SPTESTINGINC PAGE 06/09 <br /> Parcel number. _� System stetus: �Com Ilant <br /> p L7 Noncomplient <br /> (es determineuf by thia ifortn) <br /> 3oil 3eparat9o� Cotnpliance and Othe�r Co pliance <br /> Compliance Issue #3 of 4 <br /> Dete of obsenration: _7-�.,���„ Reason for ob rwatlon: �pg�-St�+f_ ��,�`s�� <br /> Thls iqiormetion on thiS fnnn does not�expire. •�`-`. <br /> • Complianct questions/ctiterla;: (Required) Ver�fiCatlon Method*�'• (Optlona!) <br /> (Checkcck the apprvpriate box) (Chech the epprvprlet�.box) <br /> For systems built pr�or to April 1,1886,end not <br /> loceted in Shoreland or Wellhead Protection � Conducted soll observafion(s) (attach boring logs) <br /> Area or not serving e food, beverage or � Two previoua verificaiions(attach borfng logs) <br /> lodging establlshment: ► �,�` <br /> 3 �o�r� � Other. �g"1 �oK 4. a,1 �P i��Z�s�Rs� <br /> poes the system have et least a two-fooi ,i � � <br /> vertical separadon distance from periddically .���, _�+ �3 �- ;� sy�µ� <br /> saturated soil or bedredc? i <br /> Yes � 0 3, I ��1,oZ 6,��¢¢„ �/CLor.L <br /> For nor�perfoRnance systems built Aprll 1, <br /> 1996,or later or for non-performance syatems <br /> located in Shoreland or Wellhead Protection �Soi�observaUon does not expl�e. Previous obs�rvations <br /> Areas or serving s food, beverage or lodging by two independent parUes are suf�dent,unless site <br /> establishment: conditions have�been aftered. <br /> • Does the system have a three-foot vertical <br /> separation dlstance from periodfcaliy satureted � <br /> soil or bedrock?" Yes N <br /> For reduced separation distance systems(i.e., ' <br /> "pertormance"systems under old 70B0.09 79 or ' May ba neduced by up fo �5 percent if allowed!n loca! <br /> Type(V or V system under new 7080.2350 or • � onpflnsnca, <br /> 7060.2400): •'No sMendai+d protoco/exlsts. This list!s not exhaustivs, <br /> Dnes the system meet the designed vertical In sequerr6al vrder, nbr dves/t/ndicare which <br /> separ�tion dlstance from periodfoetly satureted combinaUons are necessary to make thls � <br /> soil or bedrock?* Yes N determir,ation. <br /> Ady"no"answer indicete�s lhat the system is failing to protect <br /> ground water. <br /> Certification <br /> Thls form is to be completed and attsched to fhe Summary Fo ef the Minnesots Pollutlon Gontrol Agency's(MPCA)Compliance <br /> Inspection Form for Exlsting 5ubsurtace 3ewage Treatrnen Systems.Obsenret�ons,fnterpretations,and conclusions must be <br /> campleted by an inspector or designer.Completed fonn must b submitted to the locel unit of govemmant wlthln 15 deys. <br /> Property owner name(s); �� Q��L�., � , <br /> . ,,.. �` . <br /> PropeKy add�ess: ,._ a?�.}p �0 . �,2� O <br /> Property owner's add�ess(if diFFere�t): -�^� <br /> County; � ���✓� Phone: �,, ��, ^� <br /> �3�5�.��r,�Ofl <br /> �� ,. <br /> I heneby certlry that I personally mede the obseivadons,.inferpre tions,and conclusions reported on thls form and that they are <br /> correci. <br /> Name: S 1�� Q• .��]��M�..�, Certification number. _��� <br /> Bu�iness Ilc�nse namo and number: ''�7-'F� � )��,. ���c�y,��_z u p � �o� <br /> .S�Z=ZL <br /> Name of local nIt of govemment: <br /> _ �rf ��,.� <br /> Signature: � 7+ .�------ „ Date: �-9 r D� <br /> wq•wwlsts4-3! Com Un►►ce Inspection Form for Exlstino S.t7'c <br /> e�,mn p � <br />