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07/18/200� 1:58 7634975011 SPTESTINGINC PAGE 08/19
<br /> parcel numb�r: __ __ System ststus: �Compliant ❑Ncncampliarit
<br /> (as deGerrnined by thfs ftirm)
<br /> Soii S�p�ra ion Complia�hce and O�her Compliance
<br /> Complian�e �sue #3 ofi 4 �
<br /> Date of obse�rati n: �l -�-oc _ Reason for observation: __��� ..-- -.,.,,.._._..��
<br /> This�n�ormab'bn ►p fhls fnm►doas noF expire.
<br /> � Compllan� q tionslcrfteria: (Required) Verlflcation Method": (Optional)
<br /> Check th� riete box _ (Chedc the approprfate box)
<br /> For systems uilt riot to Ap�ii 1, 19g6,and not � Conducted soll observation(s)(attach bonng logs}
<br /> located in Sli�rel d or Wellhead ptbtecflon
<br /> Area or nct s rvi a food,beverelg�e or ❑ Two hrevious ve�lflcations(altach bor�ng lops�
<br /> lodging est�b�ish nt ❑ Other: ,,,, �
<br /> Does the sy�m ve at least a two-foot �
<br /> vertical sepa tio dist�nce from pe�iodically
<br /> satureted soil or drodc? ■Yes ❑ No __ _
<br /> For non-pe�fo�rna systems built April 1, , .
<br /> 1996,or later b� t non-performan�o systems Soll observation does not expire. Pre�ious observations
<br /> located in Sh�rel r1d or WeUhead Protectian by two Independent parties e�e su�iaent,unless site
<br /> Areas or serv�g food,beverage or lodging conditions have been altered,
<br /> establlshmen•
<br /> Does th�syst m e a three-foot vertical
<br /> separatien dl�tan from peNodic�lly saturated �
<br /> soil or bedroc ?" ,�_�_,,, ❑Yes ❑No
<br /> For reduced s�ep ion distance systems(l.e., * ry��y be�duced by up i�o 15 peroent if al/owed rn lacal
<br /> perfortnance s il�ms unde�old 7080.0179 or ondlnence.
<br /> 'Typ�IV cr V�ys tn under new 7080.2350 or
<br /> 7060.2A00): I "`No standerd proiocol e,�ists_ Thls list is not exheus6ve,
<br /> Does the syst�m eet the d�signetl vertical in sequenNal o►der, nor does It indicete which
<br /> seperation di an from peliodically saturat�d combinations are necessary to make this
<br /> soil ar bedroc ?' ' [�,1,jos ❑ No d@terminallon.
<br /> Any"ne"ans�vot hdica�s lhat tha system Is fa(Ifng to protect
<br /> ground water1
<br /> Certificat��n
<br /> 1'his foRn is td,be mpieted and at�eched to the Summary Form of the Minnesota Pollution Cor�trol qq�ncy's(MPCA)Compliance
<br /> Inspec6on F$rtn r�xlsUng SubsurFace S�wage Treatment 3ystems.Observations,interpretations,and conclusions must be
<br /> completed by han 1 pector or designer.Cempleted form must b�submltted to the Iocal unit of govemmerrt withln 1S days.
<br /> PropeKy own�r n me(s): �.L� ?i P_k1l►�r�r'1 ,,,_, ,..�...�,..�.....,.,.__.
<br /> Property addr�ss: 3l1�--� S��+�''� � .,_. -
<br /> Property own�r's ddres5('�f dl�ferent): �
<br /> �ounty: Phone: (QL,� S�I-�a 3.�
<br /> I hereby cerlif�fh t 1 personelly made the o6servaF/ans, interp►efations, and conclusions nepo�ed on#his fom►and that they are
<br /> colr�Ct-
<br /> Name� ,J, ���/+'�"�-� Certification number: 3°I�
<br /> Business licer�se 8me ana numbeh � r1� '��+n�a,r� �..,,, _ ____ _ or
<br /> Name of locel iunl pf ove ent: ��(Z,Q 1i'� -., �r..-...
<br /> Signature: �„ � ' Date: �41�-0$�
<br /> wv-wwisCs4•.�� Comptiance Inspectlon Form fo�Existing SSTS
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