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Parcel number: _ System status: ❑ Compliant fet 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: (' r c\ ) 0 Reason for observation:WO'' --¢ c� <br /> This information on this form does not expire. <br /> Compliance questions/criteria: (Required) Verification Method**: (Optional) <br /> (Check the appropriate box) (Check the appropriate box) <br /> For systems built prior to April 1, 1996, and not lJ 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: ,K ,r, goy ,0 <br /> ❑ Other: 'F izs.„ax.F. 3`6 ztr>'.`fY�r>lticl►i <br /> Does the system have at least a two-foot <br /> vertical separation distance from periodically <br /> saturated soil or bedrock? ❑Yes ®No q5 r ! 'I 5(air oG t.0 <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?* ❑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 an inspector or designer. Completed form must be submitted to the local unit of government within 15 days. <br /> Property owner name(s): 'D\ <br /> Property address: i I '), \A/\V..-OW84_001-- " o'c o <br /> Property owner's address(if different): <br /> County: Property owner phone: '7 2- Lt,,'— a I) <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: S� y'6.a 61, SLS Certification number: ( a r) <br /> Business license name and number: '5-52116S-6,11, 10,G, L1(:`., t) t j 't *7�j;$-49' . 3 t=4o(a or <br /> Name of local unit of government: <br /> Signature: '._6 j �_ �._ Date: 9- aa,- ao1 <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 • 4/24/09 <br /> Page 4 of 8 <br />