Septic info - Laserfiche WebLink

Home Browse Search

67/21N2008 10: 53 9528733112 PAGE 64/05 Parcel number: __ ___. __ ,_ S stem status; Compliant ❑ Noncompliant � ( s determined y r is formJ Soil Separation CotnplOance and Other Compllan Compliance Issue #3 0 4 � Oate of observation: �� Reason for observation: � 7his informaf;on on thls form does not ex�Oire. ^ � Compliance questionslcriteria: (Required) erification Method**: (Optlonal) �Check the a�propriate box) - (Check fhe appropriate boxJ 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,boverage or ❑ Two previous verlflcations (attach boring logs) lodging establishment: ❑ Other; l� �� a � rpG�y�- �oes the syslem have at least a two-foot '� / " vertical separation distance from periodically �3' � ��' � G�� !OA� saturatea soil or bedrock? , _Yes ❑ No_ �ty }TS p� ��-�� For non-performance syst2ms built Aprif.1, � •�`�.�,�� l-�aS �-�„___$d�h dC -� 1996, or later or for non-performance systems J - • located in Shoreland or Wellhead Protection oil observation does not expire. Previous observations Areas or serving a food, beverage or lodging y two independent paRies are suFficfent, unless site establlshment: nditions 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 7080.01�9 or May be reduced by up to 15 per�enl if aUowed in loca/ Type IV or V system under new 7080. 2350 or ordinance. 7080.2400): No standard profocol exJsts. Thrs list is not exhaustrve, Ooes the system meet the designed vertical in sequentia!order, nor does it indreafe whrch separation distance from periodically saturaied combinafions are necessary to make fhis soll or bedrock?' , ❑Yes 0 No determ/natian. Any"no"answerindicates[hat the systerq!s failing to pro[ect grcund wafer. Certif�cation � This form is to be completed and attached to the Summary Form of the Min esota Pollution Control Agency's(MPCA) Compliance Inspection Form for Existfng Subsurtace Sewage Treatment Systems, bservations, interpretations,and conclusions must be completed by an inspector or designer, Completed forrn must be submitted o the local unit of govemment within 15 days. Property owner name(s): _ �d NZ.Q � �.��C,� _...._.._—_..,..__. _....----- ��--�- Property address: ` -- _ �_��.,. .�- - �� _ —.. � . Property owner's address (if Cifferent): - -._ :,.----._.. t ._.-----��•-•--- County: ��n, � Ph ne: ------- ....... -•-- r��.��_ - !hereby certify thaf 1 personally made!he observatlons,interpretalrons, and conclusions reported on this form and that they are correct Name: _ ��,U�` , C rtification number: �`�,,�� . , "'J-�—_.. _ .-- Business license name and number; _�V�� a � or Name of local unit of emme Signature: � Date: 1 _��..----- wq�wwists4-31 �_,.,-„---- ,--.. . , _ . _ .