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11/05f2616 06:47 7634975611 SPTESTINGINC PAGE 04109
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<br /> � Parcel number. , ___ __". ,__._ _ �. . , System status: �J Compliant ❑Nonc�mpliant
<br /> ..�,. _- �� (as detemtinod by this fiorm)
<br /> Soil5eparation Connpli�nce and Other Com�liance- Complia�ce Inspecfion Form forExisting SST�
<br /> Compliance Issue #3 of � j
<br /> Date of observatlon: �� .a,g-ao�� Reason for observation:�.�o4��"� �'Prt�kl.1S� ,_ �
<br /> �
<br /> 1'his infnrm�Nan on this form does not expim. ;
<br /> Compliance questions/criterfa: (Requlred) Ve�ification Method*": (Optlonel) �
<br /> . _(Check the app►vpriate box) ..,..,,._ (Checic the appropriate hox)
<br /> For systems built prlor lo Aprll 1, 1996,and not � Conducted soil observation(s)(attach boring bgs)
<br /> localed in Shoreland or Wellheed Protection
<br /> Area or not serving a food,beverage or ❑ Ywo prevfous veriflc�tions(attach boring logs) �
<br /> lodging establishment; � ►
<br /> ❑ Other. �.t5d..__'�'_�.��.�1?I�►.c9�.—._.�.�
<br /> Does the system have et least a two-foot
<br /> vertical sep�ratlon dislance from periodically � �`� ��'������-���I
<br /> satureted sofl or bedrock? �Yes 0 No s0�,. ..._�
<br /> , . y ��_ T_.._
<br /> For non-performance syslems bullt Aprll 1,
<br /> 1986,or later or for non-performance systems Soil observadon does not ire. Previoua observahons
<br /> Iocated in Sho�eland or Wellhead Protection by Iwo inde endent a�tiesre suffiaent, unleas sit� I
<br /> A�eas o�se►ving a food, beverage or lodging P P
<br /> estoblishment: conditions have been altered_ �
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<br /> Dv�s the system have a three-foot vertical !
<br /> separafion distance from periodically saturated :
<br /> soil or bedrack?" �Yes ❑No i
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<br /> For reduced separadon distance systems(I.e., '
<br /> 'pertortnance"systems under ald 7080.0179 or * May be►educed by up ta 95 pencent If ellowed in local �
<br /> Type IV or V sysiem under new 7080.2350 or ordinence. �
<br /> 7080.2400): "No standard protocol exists. 77iis list is not exhaustive, �
<br /> Does the system meet the designed vertic�l In sequenHel order,nor does It!nd(cet�e which i
<br /> separatlon dlstance from peflodically saturated combinatlana ere necessery to make thls ;
<br /> soil or bedrock?' �Yes �No defer►ninAtion.
<br /> Any"no"answsr indicatas that the system is fail/og!�o proMc! i
<br /> ground water. �
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<br /> Cert9fication �
<br /> Thls fo�m Is to be completed and attached to the Summary Form of the Minnesota Pollution Cantrol Agency's(MPCA)Compliahce ,
<br /> Inspectlon F�rn�for E�cisting Subsu�fiaca Sewage Treatment Systems.ObservAflons, InRerpretations,and conclusions must be ;
<br /> completed by an inspecior o�deai�rt�r.Completed form must be submflted ta lhe local unit of govemment within 15 days. ;
<br /> Property owner name(s): ��i'�i.'�'rG��.���....�.....�.�,.��......_ _,...__—;
<br /> Property address: �'�5 �0� �►-�u�,:�._.."_�-�..�`.".�,__��• _.���v . .---I
<br /> y, ..
<br /> Property owner's sddress(ii dlR�er�nt): ,.,.. ___..__.,.. �
<br /> County- }��}-��''�'Q 1�� _ Property owne�phone: (p��� 2�,°y,^,��' U a,���--�,
<br /> �—�
<br /> 1 hereby ceKify fhaf 1 personally made the o6servetions, inte►prietelions, and conclusions r�ported on this form and that fhey ere '
<br /> co►rect. ;
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<br /> Name• .,.S�{��/��.\. �,,, , L1a__� Certification number:
<br /> • ... . 5.,., . 1'����.� (r�r�� . ._
<br /> 9usiness I'�ense name and number. �S�rr'��.�J:,I1�.,.,..1..1,1_C�_�—....Vl..(`..;�M �`� '�`�'),Ia�'����..''.��..3�S,as�_ �� �
<br /> Name af local unil of govem ent �
<br /> — .. _ � _..__....._.— .._..._..._ ..._.. �. i
<br /> Signature: � . �' �-�.�-"_.---... ,....,...__.------ �ate: _���'7��0'1• I ;
<br /> r, ....... -^- ----i
<br /> ..�.�..��� ���a� ..�.� ... /r� 1/�/ /1�I� 1�I�/� I�1 7%� ��11 II• qM Y��r� w�w •�w w�i i • �� •• • �. N . � �
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