2009 - MPCA compliance inspection form

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Parcel number: System status: Compliant p ❑Noncompliant (as determined his form) Soil Separati<.;n Compliance and Other Compliance Compliance Issue #3 of 4 Date of observation: O Reason for observation: This information on this form does not expire. Compliance questions/criteria: (Required) Check the a..ro.riate box Verification Method**: (Optional) For systems built prior to April 1, 1996, and not (Check the appropriate box) Conducted soil observation(s) (attach boring logs) located in Shoreland or Wellhead Protection Area or not serving a food, beverage or • lodging establishment: ❑ Two previous verifications (attach boring logs) Does the system have at least a two-foot ❑ Other: . Air.,- �� • vertical separation distance from periodically R£ Y A� a2r7 Y saturated soil or bedrock? ❑ Yes ❑No For non-performance systems built April 1, 1996,or later or for non-performance systems Soil observation does not expire. Previous observations located in Shoreland or Wellhead Protection 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?* &1 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 local Type IV or V system under new 7080. 2350 or 7080.2400): ordinance. **No standard protocol exists. This list is not exhaustive, Does the system meet the designed vertical separation distance from periodically saturated in sequential order, nor does it indicate which soil or bedrock?* combinations are necessary to make this ❑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): Property address: c�i p-O . C., Property owner's address (if different): County: Phone: /hereby certify that I personally made the observations, interpretations, and conclusions reported on this form and that they are correct. / Name: 14*-A.Ar✓ •1a. dr-AL-d Certification number: 7'S Business license name and number: 4 Name of local unit oi`government: r1 °P Signature: .� 1.� Date: wq-wwists4-31 1/1/08 Compliance Inspection Form for Existing SSTS