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05/09/2011 10:06 9528733112 PAGE 01101 <br /> System status: Compliant C]Noncompliant <br /> Parcel numbet. _.,_..._.—.--__�l^' (as determinedhis form) <br /> Soil Separation Compliance and Other Compliance <br /> Compliance Issue #3 of 4 Al, — ^— <br /> Reason for observation: <br /> Date of observation: <br /> This information on this form does of expire. Verification Method"', (Optional) <br /> Compliance questionslcriteria: (Required) (Check the appropriate box) <br /> Check the a ro nate box Conducted soil observation(s)(attach boring logs <br /> For systems built prior to April 1, Prot and not � Two previous verifications(attach boring logs) <br /> located in Shoreland or W ellhead Protection^�� 0 <br /> Area or not serving a food,beverage or [] Other: <br /> lodging establishment: 19 <br /> Does the system have at least a two-foot )0 ✓�� <br /> vertical separation distance from periodically Yes No `�. v► <br /> w i 1�vkvS <br /> saturated soil or bedrock? � <br /> For non-performance systems built April 1, Soil observation does not expire.Previous observations <br /> 1996,or later or for non-performance systems tection by two independent parties are sufficient, unless site <br /> located In Shoreland or Wellhea Prolodg g conditions have been altered. <br /> Areas or serving a food,beverage <br /> establishment: <br /> Does the system have a three-foot vertical <br /> separation distance from periodically saturated E3 Yes ELNo <br /> soli or bedrock?' to 15 percent if allowed in local <br /> ' <br /> For reduced separation distance systems (I.e., May be reduced by up ordinance- <br /> TypeormanceIV or V system under newems under 17080 23 0.0 17 0 or r <br /> "• No standard protocol exists. This list is not exhaustive. <br /> 7080.2400): in sequential order, nor does it indicate which <br /> combinations are necessary to make this <br /> Does the system meet the designed vertical determination, <br /> separation distance from periodically saturated Des YNo <br /> soil or bedrock?' <br /> Any"no"answer indicates that the system is failing to protect <br /> ground water. <br /> Certification ta <br /> This form is to be completed and attached to the <br /> e Treatment Systems.Observations, interpretations,ontrol Cand(conclusions ns mulst be <br /> Inspection Form for Existing Subsurface g <br /> completed by an inspector or designer. Completed form must be submitted to the local unit of government within 15 ays. <br /> Property owner name(s): 1-1 <br /> Property address: <br /> Property owner's address (if different): -- <br /> County: � Phone: _.. .-------• -------._. .. . <br /> I hereby certify that(personalty made the observations, interpretations, and conclusions reported on this form and that they are <br /> correct. J <br /> Name: �� L,11 ] Certification number; <br /> Business license name and number: L � —�P.'I` MRS r/��'r— _ o� <br /> Name of local unit over 57) <br /> en : „•_ <br /> Signature: Date:37�p <br />