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67119/2011 21:33 7634975011 SPTESTINGINC PAGE 66/99
<br /> Parcei number; �,_ System status: � Compliant ❑ Noncompliant
<br /> ��""�� (as defermined by this form)
<br /> Soil SaparatOdn C�ompliance and Olher ComipM�ance , Compliance Inspection Fo�n for Existing SSTS
<br /> Compliance Issue #3 of 4
<br /> Date of obseivatlon: 7 � 1 1 � o��f 1 Reason far obsen►atfon: 'P�O�Q��1�'��5�('r��� ^�^,_
<br /> This informeNon on this form does not expire.
<br /> Compllance questiot�s/criterla: (Requlrec� Verification Method**: (Optional)
<br /> (Check rhe��dropriete box _�._,.� (Check the appropriate box)
<br /> Fo�systems built prior to Aprll 1, 1996, and not � Conducted soil observatlon(s)(attach boring logs)
<br /> located in 5horeland or Wellhead i'rotection
<br /> Area or not serving a food,beverage or ❑ Two provious veMflcations(attach bvring logs)
<br /> lodging establishment: ❑ Other:
<br /> aoes the system have at least e two-foot �~�
<br /> vertical separation dlstance f�om peiiodir�lly —
<br /> saturated soil or bedrock? ❑Yes ❑ No
<br /> For non-performance systems built April 1, ��,,,.._��x
<br /> 1996,or later or ivr non-perFonnance systems Soil obsorvation does not expine.Pravious abseroatlons
<br /> located in Shoreland or Wellhead Pratection
<br /> Areas or serving a food, b�verage or lodging by two independent parties are sufficierrt,unless site
<br /> establlshment_ condltions have been altered.
<br /> Does the system have a three-foot veRlcal
<br /> separ�tion distance from periodi�ally saturated
<br /> soil or bedl'�ck?* Yes ❑ No
<br /> Fo�reduced separation distance systems(I,e.,
<br /> "performance"systems under old 7080,0179 or " May be►educed by up b 15 percent If ellowed in local
<br /> Type IV or V system under new'�080.2350 or o►tlinance.
<br /> 7080.2400): *'No standard protocol exlsts. TI7is list is not exhaustive,
<br /> Does the system moct the designed vertical fn sequenfial order, nor does it indlcate which
<br /> separation distance from pehodlc�lly saturated combi�afions ar�necessary to make this
<br /> soil or bedrock?' �Yes � No determinaf.ion,
<br /> Any`"no"answer indicates that the system Is faflfog fio protect
<br /> ground wat�r.
<br /> Certificafiion
<br /> This form is to be completed and att�Ched to the Summary Form of the Minnosota I�ollutlon Control Agency's(MPCA)Compllance
<br /> Inspection Form for Exl�ting Subsurtace Sewage Treatment 3ystems.Observatlons, interpretatfons, and conclusivns must be
<br /> completed by an inspector or designer_Completed form must be submitted to the local unit of government within 15 days,
<br /> Property owner name(s): 5 Lq��,�,/_� ,._,,., ...-
<br /> Property address: 2l 1�1� C., �1'L��� �•�A ' _ �'�4.�o -..,,. •..• —_.._,_ ,.......
<br /> Property owne�s eddress (it'd��nrent); _ ,
<br /> County: �'�}�,�_��_� Property owner phone: �p6L" �a 0 ^ !+ l,0 _�_____,.,_,_
<br /> 1 hareby certlfy that 1 persanally made thQ observabons, interpretatfons, and concluslons reported on tfi/s fom►and that they ere
<br /> carrect.
<br /> Name: , ��V�G�..� �. ,SL�-11�11���5 �__.___ Certitication number. (��►� �,,,,,�„�,
<br /> Business Iicanse name and number. 5-4' ;{�'S��.1 L:��I,.�_,�_,L'�'� 3`�� '�I�..3.-�► Q123�Se�^, or
<br /> Name of local hi� t of gover�nment• _„� ,:_. �. -
<br /> Signature: G���'��'. ,� "� ,_ � _
<br /> Date: �LS�...a.J�l--.__..�...
<br /> .�. '_' _�' '��� ...... ..� .... rr�..�� �n� e��� ...nnn cC�iOc� _ A.�.il.l.l.......Ir.....�w....t........�.
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