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Parcel number' System status: ®Compliant 0 Noncompliant (as determined by this form) Soil Separation Compliance and Other Compliance—Compliance Inspection Fom1 for Existing SST, Compliance Issue#3 of 4 Date of observation: l 1-V- a olo Reason for observation:Q'lrgy(.+t This information on this form does not expire. Compliance questions/criteria:(Required) Verification Method**:(Optional) Check the a•• 'tale box (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: ❑ Other 3,S Rf 3 M tGRONa'()as.� Does the system have at least a two-foot vertical separation distance from periodically 'f 4 ? 1.75))446n-.. SAgf■»tyf saturated soil or bedrock? Yes ■ No • SpyL 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 by two independent parties are sufficient,unless site Areas or serving a food,beverage or lodging establishment: conditions have been altered. Does the system have a three-foot vertical separation distance from periodically saturated soil or 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 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?* M Yes •No determination. Any"no"answer indicates that the system Is falling to protect ground water. • Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPGA)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): S3'.J o Property address: 56 a0 So. OLp Clir4SKAL,SA4 ' o ) 0'10140 Property owners address(if different): County: )4f4.11--\'02y y Property owner phone: 9 5'1.-4')5.- a o S4 I hereby certify that I personally made the observations,interpretations,and conclusions reported on this form and that they are correct. Name: S-1 -N.41..) Certification number: (oat) Business license name and number: Cj-Q'e1iY.11,11, i#1P• 1<1G,*3`) Iv;w'to3-tri 9..$SI,(m or Name of local unit of government: Signature: �1 �i,,(._ Date: ll')1)•-•a(9)D www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats wq-wwlsts4-31 • 4/24/09 Paye 4of8