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11/19/2011 04:32 7634975011 SPTESTINGINC PAGE 04/07
<br /> Parcel number: ___ __ ^, _,� System status; ❑ Compliant � Noncompliant
<br /> (as del�ennined by fhis form)
<br /> Sopl Sepa�ra�tlor� Cornplpa�nce and Other Corr�ppiance- Compliance Inspect�ion Fo�m for Exist,ing SSTS
<br /> Compliance Issue #3 of 4
<br /> Dete of observAtion: � ��,�_
<br /> —U_....,_�a�t �,„ Re�son for observaUon:. Q �
<br /> Thls info►mation on t,his fnrm does not explr�e. •
<br /> Cvmpliance questi4�ns/criteria: (Required) VerrFicatlonl Method": (Option�l)
<br /> , Check fhe sp�rieh�box) __ ,,,_ (Check fhe apprvpriafe box)
<br /> Far systems bullt prior to Ap�il 1, 1996, end not � Conductod soil obsenration(s)(attach boring logs)
<br /> located in Shoreland or Wellhead Protection
<br /> Area or not serving a food,beverage or [] Two previous verlflcations(altach boring logs)
<br /> lodging establishment:
<br /> ❑ Other. lo"��n q.�.l �.��z���1�7�,�
<br /> Does the system have at least a two-foot �
<br /> verticat separatlon distance frorn periodically :5�� ��0�?i���!�,_�f�Q���j
<br /> _saturated soil o�bedrock?_ ,� ❑Yes ��No ���
<br /> For non-performance systems built April 1, �
<br /> 1896,or later or tor non-performance systems � �-� -��•—
<br /> located i�Shoreland or Wellhead Protection Soil observ�tion does not oxpire. Previous obs�rvetions
<br /> Areas or serving a food, beverage or lodging by two Indcpendent parties a�e sufficient, �mless site
<br /> establlshm�nt: conditions have been altered.
<br /> Does the system hav�a three-foot ve�rtical
<br /> separation dislance from periodicall,y saturated
<br /> soil or bedrock?* _ , � ❑Yes �No
<br /> For reduced separation distence systems(i.e.,
<br /> "perFormance"systems under old 7080.0179 or ' May be reduced by up(0 15 percEnt if ellowed!n Iocal
<br /> Type IV or V system under new 7080.2350 or ordinance.
<br /> 70802400); *'Na srandard protocal exisfs. This list is nof exhaustive,
<br /> Does the system moet the designed vertical in sequenfia/arder, nor does it indicat�e which
<br /> sepa�ation distance fmm pe�lodically saturated com6lnations are necessary fo m�ake lrifs
<br /> soil o�bedrock?" . � __ Yes 0 No deteimine�ian.
<br /> Any"no"answer indicatEis that the systam is fa1/Ing to protect
<br /> g►aund waitie►:
<br /> Certification
<br /> This form is to be completed and ettached ta the Summary Form of the Minneso�ta Pollutivn Control Agency's{MPCA)Compliance
<br /> in9pection Forr�for Existing Subsurtace Sewage Treatme�nt Systems.Observations, interpretatlons,and conclusions must be
<br /> compleked by an inspector or designer.Completed farm must be submitted to the local unit of govemment within 15 days.
<br /> Property owner name(s)= �G�1��� ���,��� � � _ _ _,W
<br /> . ��.. ... ,..—
<br /> Properky address: �_�O 'U� 11a 'L�1r�r,1�1.Q c?'P�t��..._.,.
<br /> �M _---— ,,,� . ��
<br /> Property owner's address(fF diifior�nq:
<br /> Count�r: _ ` \ _ a_�j, Property owner phone: ,(�I Z ^ �t��o��_
<br /> I hereby cerfl�y that 1 personally made�he observaHons, interpretations, and concJusions reported on�his form and that,they ar�
<br /> correcr.
<br /> Name: ����/�r��{�, �(��..q����G�^15 _, Certificatlon numbEr: _._./,��,�
<br /> Business Ifcense name and number: s-Q -{��.-���� � , � ''•�' 3 '� � , „
<br /> 1�..__1._�l1��-1.�r_�.��_'�.�19��Z'3_�(a ` or
<br /> Namo of locel unit of�overnment: •
<br /> _:,__.......:- ----�-,—
<br /> Signature: � ,
<br /> � -_.-.... .._.
<br /> _..
<br /> ____...,�' Date: I
<br /> -. .._ .�..1���.Q���__, �
<br /> unniw nr� ct�fm m� u� . . 'RKI_DO6.,L71V1 _ OM GGY �O�� rr�.„-. ...,� .,,. ,,,,.. .-- --• • •--.... .. .. . " •�'.
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