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Parcel number: System status: ' le Compliant ❑ Noncompliant <br /> (as determined by this form) <br /> Soil Separation Compliance and Other Compliance - Compliance Inspection Form for Existing SSTS <br /> Compliance Issue #3 of 4 <br /> Date of observation: I l-1 1- -0"t Reason for observation: _ <br /> This information on this form does not expire. <br /> Compliance questions/criteria: (Required) Verification Method**: (Optional) <br /> (Check the appropriate box) i (Check the appropriate box) <br /> For systems built prior to April 1, 1996,and not I ® Conducted soil observation(s)(attach boring logs) <br /> located in Shoreland or Wellhead Protection <br /> Area or not serving a food,beverage or ❑ Two previous verifications(attach boring logs) <br /> lodging establishment: I ❑ Other: 3. . CV/'v, 3•'J F 6.~-1 A"C1A}3, <br /> Does the system have at least a two-foot <br /> vertical separation distance from periodically <br /> saturated soil or bedrock? ❑Yes ❑ No <br /> For non-performance systems built April 1, <br /> 1996,or later or for non-performance systems <br /> located in Shoreland or Wellhead Protection Soil observation does not expire. Previous observations <br /> Areas or serving a food, beverage or lodging by two independent parties are sufficient, unless site <br /> establishment: conditions have been altered. <br /> Does the system have a three-foot vertical <br /> separation distance from periodically saturated <br /> soil or bedrock?* 'S Yes ❑ No <br /> For reduced separation distance systems•(i.e., <br /> "performance"systems under old 7080.0179 or * May be reduced by up to 15 percent if allowed in local <br /> Type IV or V system under new 7080. 2350 or ordinance. <br /> 7080.2400): **No standard protocol exists. This list is not exhaustive, <br /> Does the system meet the designed vertical in sequential order, nor does it indicate which <br /> separation distance from periodically saturated combinations are necessary to make this <br /> soil or bedrock?* ❑Yes ❑ No determination. <br /> Any"no"answer indicates that the system is failing to protect <br /> ground water. <br /> Certification <br /> This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compliance <br /> Inspection Form for Existing Subsurface Sewage Treatment Systems. Observations, interpretations, and conclusions must be <br /> completed by aninspector or designer.Completed form must be submitted to the local unit of government within 15 days. <br /> Property owner name(s): ) j LDS- V IAUT1PrC'C <br /> Property address: "X„0/4,2 L3Or-c ,,jpt„t)}.1 Q psC) <br /> Property owner's address(if different): <br /> County: 1,,5, . ;` }$,,C Property owner phone: (1,0. )'3 - a <br /> I hereby certify that I personally made the observations, interpretations, and conclusions reported on this form and that they are <br /> correct. • <br /> Name: 6(_,\-111--M rcn Certification number: <br /> Business license name and number: }136. LtG z0) t ..)% - 917 - 3 S 47 Go or <br /> Name of local ynit of government: <br /> Signature: (7 r � '- Date: )J - ) --^0 c) , <br /> www.pca.state.mn.us • 651.296=6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats <br /> wq-wwists4-31 • 4/10/09 Pose 4 of 8 <br />