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Parcel number ___ — System status: (Compliant 0 Noncompliant -- (as determined by this form) Soil Separation Compliance and Other Compliance Compliance Issue #3 of 1 1 ,, Date of observation: 10 11 Reason for observation: ci(h�.tc� -- — This information on this form does 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 +0 Conducted soil observation(s) (attach boring logs) located in Shoreland or Wellhead Protection Area or not serving a food, beverage or 0 Two previous verifications (attach boring logs) lodging establishment: ❑ Other: 11 01 . ''P g!`iot /��N/n- Does the system have at least a two-foot IS - /f.' Y4 v7 e/er1.,14°� vertical separation distance from periodically $ /7 3 saturated soil or bedrock? ■ Yes I No pp ( 2^ For non-performance systems built April 1, ill OA W I 1.a Ot �� _-- 1996,or later or for non-performance systems Soil observation does not expire. Previous observations Areas in er Shorelandfor Bever ad Protection lodging by two independent parties are sufficient, unless site est a l 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?' _ 1_4 Yes I No For reduced separation distance systems (i.e., May be reduced by up to l5 percent if allowed in local "performance"systems under old 7080.0179 or ordinance, Type IV or V system under new 7080. 2350 or 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 combinations are necessary to make this separation distance from periodically saturated determination. soil or bedrock?' 0 Yes pa No,-•_ 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): ___5kr t _`I gikr Property address: . 1270 We ger/ owner's address(if different): -- ' - -- - Phone: ---- - County: _�� - ---.. •. I hereby certify that I personally made the observations, interpretations, and conclusions reported on this form and that they are correct, - !� `- (� Name: Certification number: t'S�t.(?5"1 _—. ..-- Qdrl�nd S 1�S v\� a.oa. - _ -- or Business license name and number: - Name of local unit vernm- . / / - _-- Signature: i f// ..4 _ Date: AO wq•wwisrs4.31 Compliance Inspection Form for Existing SSTS 4/1/08 50/7e 39dd Z1TEEL8Z96 9T :ZT TT9Z/170/13I