|
11f16/,2611 02: 31 7634975011 SPTESTINGINC PAGE 05109
<br /> Parcel number: _ ` � � System status: �Com lianl
<br /> p ❑Noncompliant
<br /> (as determined by thls form)
<br /> Soil Se�ara�non Co�mplOar�ce and Other Complaance- Compliance/nsp�ction Form for Existing SSTS
<br /> Compliance Issue #3 ofi 4
<br /> Date of obseroation: �� –�,_ –a� �� Reason for observation; ''Q�'���"��.�4�� ��
<br /> This lnformatlon on this form does not expire. • •
<br /> Complla�Ce qu�estionslcriitetia: (Required) Ve�ificatlon Method"'"• (Optional)
<br /> �Check th�appmp�ate box) '
<br /> (Check fhe appropriato box)
<br /> For systems built prior to April 1, 1996, and not
<br /> located in Shoreland or Wellhead Protection � Conducted soil observation(s)(attach boring loga)
<br /> Area or nvt serving a food,beverage or �] Two previous verifications(attach boring logs)
<br /> lodging establishment:
<br /> ❑ Other: -�7.�.��.�1'r__ � S�,_�-C�LqJ�
<br /> Does the system have at least a two-foQt
<br /> verticel separatlon diskance fram perlodically �i,���S D��,��j,,�
<br /> saturated soil or bedrock? �Yes [�No� ,y��.���5�1��� �
<br /> For non-perf�ormance�ystems bullt April 1, "'
<br /> 1986,or later or for non-perFormance systems ---� ...�_„
<br /> located in Shoreland o�Wellhead Protectlon Soi)observation dods not expire. Previous observations
<br /> Areas nr serving a food, beverage or lodging by two independent parties are sufficlent, unless site
<br /> establlshment: conditions have been altered,
<br /> Does the system have a three-foot vertical
<br /> separation dlstance from periodically saturated
<br /> soil or bedrock�• _�Yes ❑ Nv
<br /> For reduced seperetlon distance systems(I.e.,
<br /> "performance"systems under old 7080.0179 or ° May be reduced by up tn 95 porcent if allowed in loca!
<br /> Typo IV or V system under new 7080_2350 or ordlnance.
<br /> 7080.2400): "'No standard protocol ex/sts. Thrs list Is nof exhaus�lve,
<br /> Does the system mee�the deslgned vertical ln sequential order, nor does!t indica(�e whicll
<br /> separatlon distance from periodically saturat�d combina�ions are necessary b make tl�ls
<br /> soil or bedrock?` „ , ,�Yes No detennlnafion.
<br /> Any"no"enswer Indir.a[+�s that the syst�m is failing M protect � •
<br /> ground watgr.
<br /> Certification
<br /> This form is to be completed and attached#o the Summary Form of the Minnesota PolluHon Control Agency's(MPCA)Complianca
<br /> Inspection Form for IExisti�g SubsUrFace 3ewage Treatment Systems.Observations, Interpretations, and c�nclusions must be
<br /> completed by an inspecto�or designer. Completed form must be sUpmitted to the Iocal unit of govemment within 15 days.
<br /> Property owner name(s): ��V�+ ._G�\ e,,��:_ .� �_����^�
<br /> ��
<br /> Property address: r�Ie°1 � L o�1��"��;�L��. �� ..���. (,,����_V, ' �
<br /> Property owner's address(if ditFereni): �`�~r � `
<br /> County: �_.�41.���.��. y Property►awner phone: �("�, �' �(Op � �e? (p-� , '
<br /> 1 har�by certify t,haf I�ersonallN made tNe obse�vations,fnferpretatlons, and concluslons report�d on this form and that thoy are
<br /> corrnct.
<br /> Name: S�� .� =' ,_ S L�..�1���..5 „w Certification number: ���_
<br /> Buslness license name and number: 5 -Q-��S-- -S�;�1 L-, .) �y�_4i L'���m�`�y�.2��,���?_ ..���� _ o� �
<br /> N�me of local ni of govem�ent: __,_ �V
<br /> Signature: �%L�+�-- "'� * �"'�`'�'.�,'.. ,» . ,�a.a J � " ,,,—
<br /> Date: ap
<br /> www.pta,state.mn.uS + 651-296-6]00 • 800-657-3664 • TTY 651•Z82•5332 ��^
<br /> ..�.._.,_._, .. .,..,.__ OC 800•657-38b4 • AVBilahla in altamahiv�f,...,,�N
<br />
|