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04/26/2010 07:28 9528733112 PAGE 64165 ,.,5 .; ,.�� Parcel number: __ _ _ System status: Compliant ❑ Noncompli�nt (as determined y his form) Soil Separatlon Complia�ce and Other Compllance Compliance Issue #3 f 4 ' Oate of observation_ I 1 � � Reason for observation: JC� �. This inTormat;on on lhis iorm does not expire_ 'y Compliance questionslcriterla: (Requi�ed) Ve�ification Method"`: (Optional) �Check the a ro rlate box (Check ihe appropriafe box) For systems built priorto April 1, 1996, and not �Conducted soil observation(s}(aitach boring logs) located in Shoreland or Wellhead P�otection Area or not serving a food,beverage or [] Two previous verlficatlons (attach boring logs) lodging establishment; ❑ Other: Does the system have at I�ast a two-foot '� ""- "-�'— vertical separation distance from periodically ^,_ saturated soi�or bedrock? Yes ❑ No For non-pertormance systems built Aprll.1, ^T� 1996, or later or for non-pertnrmance systems �' ---��--- located in Sho�eland or Wellhead Protection Soil observatlon does not expire, Previous observations Areas or serving a food, beverage or lodging by two independent parties are sufficient, unless site establishment: conditlons have boen 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 undar 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 protoco!exists. This liSf i5 not exhaustive, Does the system meet the designed vertical in soquential order, nor does ir indicate wh�ch separation distance from periodically saturated combinatrons are necessary to make th+s soil or bedrock?' ❑Yes No determination, Any"no"snswer indicates fhat fhe system!s failing fo protect ground water. Certification � This form Is to be completed and attached to the Summary Form of the Mlnnesota Pollution Control Agency's (MPCA)Compliance Inspectfon Form for Existing Subsurtace Sewaee Treatme�t Systems. Observations, inte�pretations,and conclusions must be completed by an inspector or designer.Completed form must be submitted to the Iocal unit of govemment within 15 days, Property owner name(s): _,.,�F "�'�%�• ��.!'�' ';� ' �/ Property address: � '� '�� W� � S �� ` � ----_._..�_.___ -----�.,. �� _.._ o , �.� Y U_U.±Q-- — -- ..... Praperty owner's address(iFdlfferent}� County: �1f V��1, ^1 VL Phonc_ ,. —.--....... . _... ._ � _...._._�_— _ ... I hereby ce�t�fy that 1 persona!!y made the observatlons, interpretations, and conclusions r,�ported on this form and�hat they are correct, Name: _ . - � � r Ce�tiflCatiion number: �'�� Business�icense name and number; j��}1� ��U1lg <,� ��L ��C7�, _._ or Name of local unit of g men� / .�_ � __ Signature: --"�Q Date: � // �1� wq-ww15ts4•3� ('mm�linn��, I�rn.,�.i.... C....., c..� r,-_'.:__ r�-rr