2690 Rainey Road - Septic Compliance

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Parcel number: System status; Compliant ❑ Noncompliant (as determinedZY, t is form) Soil Separation Compliance and Other Compliance Compliance Issue #3 of_4 Date of observation: Q-54— Reason for observation: This information on this form does not expire, Compliance questionslcriterla: (Required) For systems built prior to April 1, 1996. and not located in Shoreland or Wellhead Protection Area or not serving a food, beverage or lodging establishment: Does the system have at least a two -foot vertical separation distance from periodically For non-performance systems built April 1 — 1996, or later or for non-performance systems located In Shoreland or Wellhead Protection Areas or serving a food, beverage or lodging establishment: Does the system have a three-foot vertical separation distance from periodically saturated For reduced separation distance systems (i.e., "performance" systems under old 7080.0179 or Type IV or V system under new 7080. 2350 or 7080.2400): Does the system meet the designed vertical separation distance from periodically saturated Any "na" answer Indicates that the system Is failing to protect ,ground water. Certification Verification Method"*: (Optional) (Check the appropriate box) Conducted soil observation(s) (attach boring logs) ❑ Two previous verifications (attach boring logs) Cl Other: k 1 i 9 a. I- QA )o�_�s Soil observation does not expire, Previous observations by two independent parties are sufficient, unless site conditions have been altered. May be reduced by up to 15 percent if allowed in local ordinance, No standard protocol exists. This list is not exhaustive, in sequential order, nor does it indicate which combinations are necessary to make this delerminetion. This form Is to be completed and attached to the Summary Form 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 rm must be submitted to the local unit of government within 15 days. Property owner neme(s); Property address: Property owner's address (it different): — County: Phone: _ ----.. •--• ..._ ... i hereby certify That I personalty made the observations, Interpretations, and conclusions reported on this form and that they are correct. Name: 14t 11 `` Business license name and number Name of local unit of 3M t: Signature: wq-wwisrs4.31 411108 90/00 3917d Certification number or Date: Compifance Inspection Form for Existing SSTS ZTTEELGZS6 GZ:bT TTOZ/90/90