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09/30/2010 01:02 7634975011 SPTESTINGINC PAGE 06111 <br /> Parcel number: <br /> System status: S Compliant ❑Noncompliant <br /> (83 determined by(his form) <br /> Soil Separation Compliance and Other ComplianC9_ Compliance Inspection Perm fvr Existing SSTS <br /> Compliance Issue #3 of 4 <br /> Date of observation: <br /> _�- ►�'_��,�_ Reason for observation_' ��_ �� ����,,,. <br /> This infonnstiorr on Oils Il)rm does not expire. ��Y`�^ _•—_ <br /> Compliance questions/criteria: (Required) Vertficatlon Method,-:Checir the appM date doxy (Optional) <br /> For systems built prior to April 1, 1996,and not - (Cherk the apprvprlete box) <br /> located in Shoreland or Wellhead Protection 0 Conducted soil observation(s)(attach boring logs) <br /> Area or not serving a food,beverage or ❑ Two previous verifications(attach borings logs) <br /> lodging establishment: <br /> Does the system have at least a two-foot El Other: , — <br /> vertical separation distance from periodically <br /> saturated soil or bedrodc7 Yes No a <br /> For non-performance systems built April 1, - <br /> 1996,or later or for non-performance systems _ <br /> located In Shoreland or Wellhead Protection Soil observation does not expire. Previous observations ` <br /> Areas or serving a food,beverage or lodging by two independent parties are sufficient,unless she <br /> establishment: conditions have been altered. <br /> Does the system have a three-foot vertical <br /> separation distance from periodically saturated <br /> soil or bedrock?" Yes No <br /> For reduced separation distance systems(i.e., <br /> "performance"systems under old 7080.0179 or May be reduced by up to 15 percent N allowed in local <br /> Type IV or V system under new 7000.2360 or orrilnance. <br /> 7080.2400): <br /> No standard prolocol exists. This list is not exhaustive, <br /> Does the system meet the designed vertical In sequential order,nor does it Indicate which <br /> separation distance from periodically saturated combinations are necessary to make this <br /> soil or bedrock?. d Yes _d No determination, <br /> Any"no"Answer Indicates that(lie system is failing to protect <br /> ground water. <br /> Certification <br /> This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compliance <br /> Inspection Form For Existing Subsurface SewageTreatment Systems,Observations, interpretations, and conclusions must be <br /> completed by an inspeianr or designer.Completed form must be submitted to the local unit of government within 15 days. <br /> Property owner name(s): � <br /> Properly address: <br /> Property owner's address(it different): <br /> County: property owner phone: — <br /> I hereby certify Mat I personally made the obse►ve6ons, inle►pretations, and conclusions reported on this form and that they are <br /> correct. <br /> Name; �> / CerlUlcation number. _ <br /> Business license name and number. <br /> ��`� �.c►..40�__ or <br /> Name of local nit of gov rent: <br /> Signature: <br /> 1.., hate: <br /> www.pra.state.mn.us • 651.296.6300 000.657.3964 TTY651.282 5332 or 800-657.3864 <br /> "-WwlstAvailable in alterative formats <br /> 4q-T! - 4/24109 <br /> Palo 4of8 <br />