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10/15/2009 16: 15 9528733112 PAGE 04/05 Parcefinumber: - System status:ex Compliant ❑ Noncompliant (as determined by this form) Soil Separation Compliance and Other Compliance Compliance Issue #3 of 4 Date of observation: Ai l'-I _ Reason for observation: 131[This information on this fo doe 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 Sk Conducted 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) lodging establishment: ❑ Other: 1�,4 Does the system have at least a two-foot .1 _ Z la 1 L1/6 ' vertical separation distance from periodically Q i r saturated soil or bedrock? ___ X Yes 0 No NO 111 For non-performancet systems built April .1, fit 0 Vt f 4 S r\ I 1996, or later or for non-performance systems S located in Shoreland or Wellhead Protection Soil observation does not expirerevious 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 focal 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 ❑ 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. Property owner name(s): G r_c� ` s U -in m ps o .--.. Property address: '2-e p w r LI C'PJ no.�_ Irl _ —__-• Property owner's address(if different)! County: l h.&p l ' Phone: I hereby certify that I personally made the observations, interpretations, and conclusions reported on this form and that they are correct. Name: (1 a\ur-\6 Certification number: P-.1(()_6' �((Q ' Business license name and number. SLL.2L tun 6 S.('wL2,S-.._..w� L -- or Name of local unit of gov VL L�� Signature: _ Date: _IQ - --__— wq•wwists4-31 Compliance inspection Form for xlsting SSTS ailing