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Parcel number: System status: ❑Compliant ® Noncompliant (as determined by this form) Soil Separation Compliance and Other Compliance Compliance Issue #3 of 4 Date of observation: I7 -)').p!� Reason for observation: 5� - 'O►J�S�n�� This information on this form does not expire. Compliance questions/criteria: (Required) Check thea roriate box Verification Method**: (Optional) (Check the appropriate box) For systems built prior to April 1, 1996,and not located in Shoreland or Wellhead Protection Conducted soil observation(s)(attach boring logs) Area or not serving a food, beverage or ❑ Two previous verifications(attach boring logs) lodging establishment: Does the system have at least a two-foot ❑ Other: .c�,„ 5 0 L tCopa. Q�� h vertical separation distance from periodically saturated soil or be QYes ❑ 14o For non-performance systems built April 1, N 1996,or later or for non-performance systems !`} e SGS °4-li�tS located in Shoreland or Wellhead Protection Soil observation does not expire. Previous observations 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?* Yes lo 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 ordinance. 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 separation distance from periodically saturated combinations are necessary to make this soil or bedrock?* ❑Yes0 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 Forin 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 b 9 submitted to the local unit of government within 15 days. Property owner name(s): L Property address: Gp A"je0 Property owner's address(if different): County: ' l Lip Phone: I hereby certify that I personally made the observations,.inter pr tations, and conclusions reported on this form and that they are correct. Name: s l G c Certification number: (o a r) Business license name and number: ` Name of local unit of gover ment: or Signature: - Date: 8 sts4-31 411108 1110Compliance Inspection Form for Existing SSTS 4/1/08