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08/01/2008 05:33 7634975011 SPTESTINGINC PAGE 03/05 h Parcel number: System status: ❑Compliant Noncompliant (es determined by this form) Soil Separation Compliance and Other Compliance Compliance Issue #3 of 4 Date of observation: 2-►7-0 eg Reason for observation: .5 6M This information on this form does not expire. Compliance questionsicriteria: (Required) Verification Method": (Optional) (Check the a ry ►late box ' (Check the appropriate box) For systems built prior to April 1, 1996,and not Conducted soil observation(s)(attach boring logs) located In Shoreland or Wellhead Protection Area or not serving a food,beverage or ❑ Two previous verifications(attach boring logs) lodging establishment: ❑ Other; IMo454ltG7 59 1 ,, .arfaoon��VY�s Does the system have at least a two-foot vertical separation distance from periodically 5"ii'°5 - mar„ J& ? • 21L _saturated soil or bedrock? Yes Jo SO,4<0Y1,i o � -AA 011 �l For non-performance systems built April 1, 1996,or later or for non-performance systems 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. i Does the system have a three-foot vertical separation distance from periodically saturated soil ar bedrock?` Yes No 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 7060.2350 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?' I Yes o determination. Any"no"answer Indleates that the system/Is failing to protect ground wager. Certification This form is to be completed and attached to the Summary Fonn 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 a submitted to the local unit of government within 15 days. Property owner name(s): Vj�QAIM Property address; Property owner's address(if different): County: ti„1 do Phone: I hereby celfify that I personally made the observations,,inter pa talions, and conclusions reported on this form and that they are correct. Name: 5'�/ � , . �� ,,� Certification number: io a r) Business license name and number: 151.T � �,-� i C• W _3 q 1)LA-4 90-m or of local unit of Bove ment: Signature: Date; 7 wq-ww1sts4-31 Compliance Inspection Form for Existing SSTS e/i/nR