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05/09/2012 14: 29 9528733112 PAGE 04/05 Parcel number: ..._ System status: 14 Compliant E Noncompliant ------ (as determine. by is form) Soil Separation Compliance and Other Compliance Compliance Issue #3 of 4 4 Date of observation: 5 �� Reason for observation: le — This information on this form oes not expire. Compliance questions/criteria: (Required) Verification Method'': (Optional) (Check the appropriate box) (Check the appropriate box) For systems built prior to April 1, 1996, and not 1KConducted soil observation(s) (attach boring logs) located in Shoreland or Wellhead Protection Area or not serving a food, beverage or ❑ Two previous verifications(attach boring logs)I ,,,, lodging establishment: g n I(� I! 2- "` ❑ Other; Does the system have at least a two-foot _c" 1? '�1( li CIV /"Wi- vertical separation distance from periodically t► !^ saturated soil or bedrock? 0 Yes ❑ No _ //. For non-performance systems built April .1, 441110-777161Y— - . t`�_i_ RL 1996, or later or for non-performance systems Soil observation does note pire. Previous observations located in and or Wellhead Protection by two independent parties are sufficient, unless site Areas or serving a food, beverage or lodging conditions have been altered. establishment: Does the system have a three-foot vertical separation distance from periodically saturated soil or bedrock?* Yes 0 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 protocol 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?* _ ❑ Yes Q 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 (MPCA) 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. 4rProperty owner name(s): 1.5 Property address: L 7 6 LAI i 0 Property owner's ddress(if different) _.County; `— — _ Phone: I hereby certify that I personally made the observations, interpretations, and conclusions reported on this form and that they are correct. Name: 1 i `` N Cil t2n Certification number: 'Q.\LOS9 _ __ Business license name and number: ^ IU6 SP Ng-S `rte(..• 2-S.D ., or Name of local unit ,f�I.vemm -- - Signature: �� Date: __ 2 wrr-wwists4-31 Compliance Inspection Form for Existing SSTS