Laserfiche WebLink
RF�� <br /> - �'o� . ���°O <br /> �� <br /> Parcel number: System status: Compliant ❑ Noncomplian`t/��F ��09 <br /> (as determined�is form) 0 <br /> RpN� <br /> ��gi ���a�ati�$o ���p19���� ar�� �t��� �����iar��e <br /> �,�mpli��c� ;ssta� #� �:� �: <br /> Date of observation: / ,1 Q Reason for observation: ��(,� <br /> This information on this for does not e:;pire. <br /> Compliancequestio�s/criieria: (Required) Ve�ificaiion iVethod��: (Optional) <br /> (Check the a ro riafe box) (Check the appropriate box) <br /> For systems built prior to April 1. 1996;and not � [/�Conducted soil observation(s)(attach boring logs) <br /> located in Shoreland or Wellhead Protection <br /> Area or not serving a food, beverage or I ❑ Two previous verifications(attach boring logs) <br /> lodging establishment: <br /> I ❑ Other: <br /> Does the system have at least a t�vo-ioot I <br /> vertical separation distance from penodicalh� <br /> saturated soil or bedrock? j Yes ❑ No <br /> For non-performance systems buili April 1, � <br /> 1996, or later or for non-performance systems ; <br /> located in Shoreland or VVelihead Protection ` Soil observation does not expire. Previous observations <br /> Areas or servinc a food,beverage or lodging i by t�nro independent parties are sufficient, unless site <br /> establishment: � conditions have been aitered. <br /> Does the system have a three-foot vertical ! <br /> separation distance from periodically saturated <br /> soil or bedrock?* � ❑Yes ❑ f�o <br /> For reduced separation distance systems(i.e., � <br /> "penormance"s�stems under old 70�0.0179 or i "" May be reduced by up fo 15 percent if allo�ved in local <br /> i ype IV or V system under ne�:��7080. 2350 or ordinance. <br /> i <br /> 70802400): �I "�'No standard protocol exists. 7his lisf is not e%haustive. <br /> Does the system meet the designed vertical I in sec�uentia(order, nor does it rndicate !-vhich <br /> separation distance from periodically sah.�rated j' combinations are necessary to make this <br /> soil or bedrock?` i ❑Yes ❑ No deterrnina`ion. <br /> Any"no"ans4ver indicates ihaf ti.e syste,n is failinr to protec: <br /> gr�urd waier. <br /> �@�"i7�7Ca$]O(E <br /> This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Comglianc? <br /> ':nspec4�on Form fioo�x"sstinq Subsur�acs Se�n�aae TreaY�aent Sysfems. Observations, interpretations.and conclusions must be <br /> comp�eted by an inspector or designer. Completed fon�must 6e submitted to the local unit of govemment��vithin 15 days. <br /> Property ov✓ner name(s): <br /> Property address: ��� p v v t,�_ _J� � _�•L. <br /> r —----------- -- <br /> Property owner's address(ifi diiferent): <br /> County: �c�✓q/ Phone: <br /> 1 hereby certriy that/personally�nade rhe obseniations, interpretations, and conclusions reported on thrs form and that they are <br /> correct. <br /> i�!ame: e�t�4J e� /L 4'!-L�"It/ Certincation number: ��� <br /> Business license name and number: ,o `��S ��✓l�. '�� or <br /> — --- — ------ — --__ -- — — <br /> Name of lo nit of overnment: �� �Q�1p�f� <br /> Signatu : - . Daie: // � 5//8- S <br /> v✓G-+vwis'rs4-31 Complianc�1»speciion f=orm jo;Existrng SSTS <br /> �/iIOS <br />