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Parcel number: System status: �Compliant ❑Noncompliant (as determined by fhis form) Soil Separation Compliance and Other Compliance Compiiance Issue #3 of 4 Date of observation: .3 Reason for observation: S��t This information on this form oes not expire. Compliance questions/criteria: (Required) Verification Methoc!**:(optional) Check the a ro rrate box (Check the appropriate box) For systems built prior to April 1, 1996,and not [� Conducted soil observation(s)(attach boring logs) located in Shoreland or Wellhead Protection Area or not serving a food,beverage or ❑ Two previous verifications(attach boring logs) lodging establishment: ❑ ome�: �.p _ ic':,,�, 1 j� Does the system have at least a two-foot verticai separation distance from periodically '��--� '- '� '�J 4ti-�r saturated soil or bedroclC.� �Yes ❑No 7�'��dx Q� �S' For non-pertormance systems built April 1, 1996,or later or for non-performance systems located in Shoreland or UVellhead Protection Soil observation does not expire. Previous observations Areas or serving a food,beverage or fodging by two independerrt parties are suffiaent,unless sits establishment: conditions have been 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., "F>erFormance"systems under old 7080.0179 or " May be reduced by up to 15 percenf if allowed in/ocal Type IV or V system under new 7080.2350 or ordinance. 7l)80.2400): *'No standard protocol exisfs. This list is not exhaustive, D��es the system meet the designed vertical in sequentia!order,nor does it indicate which se>paration distance from periodically saturated combinations ate necessary to make this suil or bedrock?* ❑Yes ❑No determinafion. Any"no"answer lndicates ihaf the system is failing to proteci ground wate� CE�rtification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Contrul Agency's(MPCA)Compliance Ins pecfion Form for Existing Subsurtace Sewage Treatment Systems.Observations,interpretations,and conciusions must be cornpleted by an inspector or designer. Completed fnrm must be submitted to the local unit of govemment witt�in 15 days. Property owner name(s): Property address: �j/7 CI U � /L t.c-�� (.v c�+c �-� �i1 . Property owner's address(if different): Courrty: ��,��`L Phone: I he,•eby certify that I personally made the obseniations, interpretations, and conclusions reported on this form and fhat they are correct. .��I,�=' •i _ .. . � / �� �z�_ _ll��,r, `� , -.,, , � --------/�-- - � -- - - --- ausi,ass 4c;��a �a�;��n�l�� i��c�a�: /)y� �-,�,�� (.G/G S ' ,��j,� S�t iz v� �.cs-' .�, �—_--- Name of local unit of govemment � , � � 0��,�� Signature� �,7�_ ��-�'J� Date: v'l/�// ?� —�_ wq-wwists4-31 Compliance Inspection Form for Existing SSTS 4/1/08