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05/19/2011 20:56 7634975011 SPTESTINGINC PAGE 08/09' <br /> Lcel number: System status: @A Compliant ❑ Noncompliant <br /> (as determined by this form) <br /> �oll Separation Comlpliance and Other Compilance•- Compliance Inspection Form for Existing SSTS <br /> itompliance Issue #3 of 4 <br /> I pl <br /> late of observation: _ -, y - <br /> Reason for observation. <br /> �his Information on this form does not expire, <br /> f ompliance questionsicriteria: (Required) Verification Method": (Optional) <br /> (Check the appropriate box — (Check the appropriate box) <br /> �or systems built prior to April 1, 1996,and not I ® Conducted soil observation(s)(attach boring logs) <br /> Ibealed In Shoreland or Wellhead protection <br /> Two previous veri <br /> Area or not serving a food,beverage or m '•� ❑ ficbtions(attach boring logs) <br /> 16dging establishment: Other: k6Sff!09 L <br /> hhJ <br /> oes the system have at least a two-foot '1 o to.S, <br /> vertical separation distance from periodically <br /> ��L <br /> Yes ❑ No 9 't <br /> saturated soil or bedrock?. ..� <br /> For non-performance systems built April 1, �2�`pp���-` <br /> 1996,or later or for non-performance systems Soil observation does not expire- Previous pbseNaUons <br /> Ibc 'led In Shoreland or Wellhead Protection by two Independent parties are sufficient,unless site <br /> Areas or serving'a food,beverage or lodging conditions have been altered. <br /> establishment: <br /> hoes the system have a three-fool vertical <br /> separation distance from periodically saturated <br /> Joll or bedrock?" ❑Yes ❑No <br /> For reduced separation distance systems'(1.e., May be reduced by up to 15 percent if allowed in local <br /> performance'systems under old 1080.0179 or ordinance- <br /> Type IV or V system under new 7080.2350 or <br /> 1080.2400): "No standard protocol exists, This list 1s not exhaustive, <br /> Does the system meet the designed vertical In sequential order, nor does it indleate which <br /> ieparatlon distance from per►odically saturated combinations are necessary to make this <br /> Y <br /> _toil or bedrock?' es detennination. <br /> ❑ No - <br /> Wry"no"answer Indicates that the system is falling to protect <br /> ground water. <br /> I <br /> certification <br /> is form Is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPGA)Compliance <br /> Inspection Form for Existing Subsurface Sewage Treatment Systems.Observations,Interpretations,and conclusions must be <br /> ner.Completed fonr must be submitted to the local unit of govemment within 15 days. <br /> completed by 7n.inspector or desig <br /> Property owner name(s): <br /> ( <br /> L roperty address: <br /> Property owner's address(if dlfierent): <br /> County: � '�-� 1 �� Property owner phone: - a1�2 " y7 <br /> f hereby certify that i personally made the observations, interpretations, And conclusions reported on This foft and that they are <br /> 6orrect. <br /> 5 Certification number: <br /> f0 <br /> Name: .•�.....-..�.._ <br /> business license name and number: 5-1�_' 11:1�.�L1`►1.�Y t-►C �_'ly- -�.V =-4`-aZ'�-S-b� yr <br /> NIgnatune:ame of local lel of government - <br /> 5pate: <br /> �► .pca.state.mn.us b51-Z96=63(10 B00-657.3864 TTY 651-282.5332 or 800=657.3864 Available in alternat�oopa of 8 <br />