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10/16/2088 2e:42 9527586278 ADVANCED ONSITE INC PAGE i6
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<br /> Parcel number: �� � g � I
<br /> ,,.,,__ _ _„ ystem 5tatus; Compliant ❑ Noncompliant
<br /> (as determrnsd � this lormJ �
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<br /> Soil Sepa�atien Carnpliance and Ather Compliance �
<br /> Compliance Issue �3 o�F 4 ;
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<br /> Date of observation: "� �Y� Reason for observation: /vC/�'l y' e � �
<br /> This information on (his form does not expire,
<br /> Compliance questians/criteria: (Required) Verification Method`": (Optional)
<br /> ^ (Check the apprropnate box) w �,_ (Checic the a,o,oropriate box)
<br /> For systems built prior to April 1, 1996, and not �Conducted soil obsorvation(s) (attach boring lo s}
<br /> located ih Shoreland or Wellhead Prote�t'ion �
<br /> Rrea or not serving a fon�l, hPVPrar�n or ❑ Twa previous verifcationc (attaoh boring logs) �
<br /> lodging establishment; ❑ Other:
<br /> Ooes the systEm have at least a lwo-faot ' �" �— ,
<br /> vertical sep2raUon distance from penodically _ _
<br /> _ssturated soil or bedrock? __ (;,;lYes� ❑ No..__ � �
<br /> Fnr nnn_r�rformance systems built April 1, ��=
<br /> 1996, or later or far non-per(ormance systems -- –
<br /> located in Shoreland or Wellhead Protection Soil observation does not expire. Previous observatio�is
<br /> Areas or sorving a food, bovoragc or lodging hy two fndep�ndent partfa¢3rc cuffioicnt, unleas.eite i
<br /> esteblishmenl: conditiQns have been altered.
<br /> Does the s.ystem havo a three-foot vErtical �
<br /> separation distance from periodicafly saturated �
<br /> soil or bedrock?' '
<br /> ., Yes No , +
<br /> For reducAd sop3ration distonoe•systems (i.e.,
<br /> "performance"systems�under old 7080.A179 or ' May be reduced by up to 15 percent if a/lowed in lo�sl
<br /> Type IV or V sysiem under new 7080.2350 or � ordinence. 3
<br /> 7080,2400): °•No standard pn�toco!exists. Th/s list is not exhaus :e,
<br /> I�oes the system meet the designed vertical . in sequantiel order, nor does it indicate which I
<br /> Seperatiort distance from periodically saturated com6inations are necessary In m2ke this '
<br /> _Soil or bedrock7' _ �[] �yeg ���o doferminafion. ' �
<br /> �4ny"no"answer indicates that the system is farling to prore�ct , �
<br /> �7round water.
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<br /> �ertificafiion. � '
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<br /> This form is to be completed and attached to the Summary F�rm of the Minnesota Pollution Control Agency's (MPCA) Camplia�l4:e �
<br /> InspPeti�n Fnrtn for Existing SubBurfacc Scwoge 7reatm��n#5ystems. Ous�ivdLions,Interpretatlons, and eonuusions must �e
<br /> completed by an inspecto�or designer. Completed form musl be submitted to the local unit af govemment within 15 days. �
<br /> Property ownor n�me(s]: �� ` � ��p�� I
<br /> Property.address: ' � �–� �1..,._
<br /> ��s--���-�. �G.��� ,.�
<br /> Properry owner's ddr�Ss (Ifdifferenty: , _ I�,�
<br /> Counry: � p,t/ _, __ Phone: C! �
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<br /> 1 l�er�by certrfy thaf!parsonelly made fhe obsErvations, intcr�releiions, and conclusions reported on this form and that they a�e j
<br /> correct. �
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<br /> hJame: _���-�s..--/�-1�-•%--�/.�J��_�._....__. ^ �
<br /> (;artifirQtion numbar: � ��� �u I�.`
<br /> ausiness license name and numb ��rICF�����7� _ �, /'�� ��_,��� . ��, �
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<br /> hlamc of local unit ofigover .
<br /> Signalure: ,_., _ � ._�— _ Dr�xe: _�� –� I�
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<br /> 4�`$�sts4.3� , . �omp(lance lnspecc,on horm for�xisting S,i�S
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