Laserfiche WebLink
03/09/2010 01:28 7634975011 SPTESTINGINC PAGE 06/13 <br /> • <br /> Parcel number: status: <br /> System 5 <br /> ... _... __.,_�_._._.._.,.,....,_,. _ y ❑ Compliant PI Noncompliant <br /> • - (as determined by this form)• <br /> . <br /> Soil Separation Compliance and Other Compliance - Compliance Inspection Form for Existing SSTS <br /> Compliance Issue #3 of 4 <br /> Date of observation: J_' jE3 Reason for observation; <br /> This information on this form does not expire. <br /> Compliance questions(criterla: (Required) Verification Method"*: (Optional) <br /> ___ICheck the.appropriate box) <br /> (Check the appropriate box) <br /> For systems built prior to April 1, 1996,and not <br /> li! (attach boringlogs) <br /> Conducted soil observation(s) q ) <br /> located in Sl�oreland or Wellhead Protection <br /> Area or not serving a food, beverage or El Two previous verifications(attach boring logs) - <br /> lodging establishment; <br /> ❑ Other. _i'v10'S'� - �v_�1.,S inSt.CD <br /> Does the system have at least a two-foot , i i- LJ.__ <br /> vertical separation distance from periodically �' ,,t�_), J, �� .�g�C�-,► uJ <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 obser,aliorrs <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?' _❑Yes L:if No <br /> For reduced separation distance systems'(i.e_, <br /> "performance"systems under old 7080,0179 or " May he reduced by up to 1 5 percent if allowed in local <br /> Type IV or V system under now 7080.2350 or ordinance. <br /> 7000.2400): <br /> "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?' I]Yes 0 No determination. <br /> Any"no"answer Indicates that the system Is falling to protect <br /> ground water. <br /> • <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 an.Inspector or designer.Completed form must be submitted to the local unit of government within 15 days, <br /> Property owner name(s): v.;per,.e <br /> Property address: O <br /> Property owners address(II different): <br /> County: _.j- ' 4 Property owner phone: (.0.,$'1 - 444 •- 37,4‘71.• <br /> I hereby certify that I personally made the observations, interpretations, and conclusions reporfed on(his forth and that they are <br /> correct. <br /> • <br /> Name: ..,'S Nte.J1___Q_...tS 1___1�� . Certification number: (a a 7 <br /> Business license name and number -1,-{ -4y111�1ya ))1c_ � l • � or <br /> Name of local"nit of govern nt: <br /> Signature: <br /> Date: 3 —.act) <br /> wwwr.pca,state.mn_us • • 651.296=63100 • . 800-657.3864 • TTY 651-28Z-5332 or.t100;657-3864 • Available in alternative formats <br /> wq•wwisrs4.31 • 4/•10109 <br /> Pow,4afR <br />