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• . , Paloel number: 3 a I v a 33 too c_,5 System status: INCompliant 0 Noncompliant (as determined by this form) •Sod Separation Compliance and Other Compliance Compliance Issue #3 of 4 , q Date of observation: '7 1st/—45:,/1 Reasut ! f ousetvation: r 144-1 This intunnulton on this form does not expire -j/ '2_4/•-zoi si Compliance questions/criteria: (Required) Verification Method": (Optional) (Check the appopriate box) _-_-- (Check the appropriate box) For systems built prior to April 1, 1996, and not [ii Conducted soil observation(s) (attach boring logs) located in Shoreland or Wellhead Protection 0 Two previous verifications (attach boring logs) Area or not serving a food,beverage or — lodging establishment: 0 Other: Mr)e' ti i) Rs kis i�.i�21 �_ Does the system have at least a two-foot . I,�A cc- V 1'�rpt (Z 1 ci< ,at l� vertical separation distance from periodically s f�1 n�A� _ ti saturated suit or bedrock? �, ' Yes 0 No / `11�7`'4`For non-performance systems built April 1, 1990, or later or for non-performance systems Soil observation does not expire. Previous observations located in and or Wellhead Protection by two independent parties are sufficient, unless site Areas 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?' `(,•s ❑ No . i — For reduced separation distance systems (i.e., -perturmance"systems under old 7080.0179 or . ' May be reduced by up to 15 percent a aua.•,e;: iii tucai Type IV or V system under new 7080.2350 or ordinance. 7080.2400): "No standard protocol exists. This list is not eAnaustive, Does the system meet the designed vertical in sequential order, nor does it indicate which separation distan from periodically saturated combinations are necessary to make this soil or bedrock?' ❑ 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 torn must be submitted to the local unit of government within 15 days Property owner name(s): A-o -pi' 5 (------ E-1-/ Tc r� ) i v n_ ) �/ Property address: 5 S.c.) Wai; ✓E/Z / c,1,, - 4e_lE /7�f/C /'(/ �S) CC//2ct-Lic) A/ iii owner's address(if different): — County=�:/v/) — — Phone: CO (ct . --Z _ 9 -31 I hereby certify that I personally made the observations, interpretations, and conclusions reported on this form and tnat tray are correct. �( �/ Business license name and number: 7( C� Name: O �� / vq ' ` (.: Certification number: / ----------- _y C 67/.5G� J � / E57/ �c� 3 or k / ! --- -- Name of local unit of g rn ent. C / T t. / — 0 ,C' Date: RI-3,-Z-7ZP // ---- Signature: •tl ---- wrt-wwists4-3l Compliance Inspection Form for Exi;rins SSTS -ii,/o