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05/08/2009 14:20 9528733112 PAGE 09/09 Parcel number: -_ System status: Compliant ❑ Noncompliant (as determinedly t is form) Soil Separation Compliance and Other Compliance Compliance Issue #�30 r 4 Date of observation: .7 LV? Reason for observation: This information on this form does kot expire. - Compliance questionslcriteria: (Required) Verification Method": (Optional) Check the appropriate box (Check the appropriate box) For systems built prior to April 1, 1996,and not Conducted soil observation(s)(attach boring logs) located In Shoreland or Wellhead Protection Area or not serving a food,beverage or lodging establishment: C1 Two previous verifications(attach oring Ings) ►� stem have [I Other: 4Kp /01:tK1L_ Does the s y a e at least a two-foot .� vertical separation distance from periodically saturated soil or bedrock? 0Yes No :i For non-performance systems built April.1, � 1996,or later or for non-performance systems - �-- located in Shoreland or Wellhead Protection Soil observation es not expire. Previous observations Areas or serving a food,beverage or lodging by two Independent parties are sufficient, unless site establishment: conditions have been altered. Does the system have a three-foot vertical separation distance from periodically saturated soil or bedrock?' Yes No For reduced separation distance systems(i.e., "performance"systems under old 7080.0179 or ' May be reduced by up to 15 percent if allowed in local Type IV or V system under new 7080.2350 or ordinance, 7080.2400); No standard protemol.exists. This list is not exhaustive, Does the system meet the designed vertical In sequential order,nor does it indicate which separation distance from periodically saturated combinations are necessary to make this soil or bedrock?' IYes No determination. Any"no"answer indicates that the-system is failing to protect ground water. Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPGA)Compliance Inspection Form for Existing Subsurface Sewage Treatment Systems.Observations,interpretations,and conclusions must be completed by an inspector+ _or designer.Completed form must be submitted to the local unit of government within 15 days.a Property owner name(s): 5w_ _ Property address: --- Property owner' address (if different), �^ County: rjgPhone: -- _ I hereby cert/fy that I personally made the observations, interpretations, and conclusions reported on this form and that they are correct. Name: Certification number: � — Business license name nd nu ber: �►r[�� 5 Wer2 or Name of local unit o ver ent , Signature: — Date: .571 wq-wwists4-31 Compliance Inspection Form for Existing SSTS 4/1 inR