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03/1412009 01:21 7634975611 SPTESTINGINC PAGE 05109 <br /> Parcel number: � <br /> ..�. ,�,� Syste�status: � Compliant ❑Noncompliant <br /> (As de6ennlned by this lonn) <br /> �o�l ►e�ara#�om� Co piiar�ce and O#he�r Compllance <br /> Compliance Issue #3 �q. <br /> bato oF observation_ <br /> This info7nation o��this fonn o���d eXp�� Rea�on for observatlon_ �'-�.�4 � <br /> _°���..,Sgs'�s.r��.—. <br /> � CoPnpliance quest�ons/c iteria: (Required) <br /> __ (Check the ap�ropriate box Verlfication Method`": (Optlonal) <br /> For systems built prior to Aprf 1, 19g(i, and not �V` (C��ecic the appropriat�e boxJ <br /> located In Shoreland or Wellh ad Prdtec4ion �I Conducted soil obsanretion(s) (attach bor�ng logs) <br /> Area or not sQrving a food, b verage or <br /> lodgin�establisl�monl: � T�a preuious veriFicstions(ailach boring logs) <br /> Does the sysiem hAve et leas a iwo-foot ❑ �ther: <br /> vertical separatlon dlstance f m periodically �~ ��`�'— <br /> saturated soil.or bedrock7 � �Yes � � '�'----- <br /> '-- .�p No <br /> For non-perFo�mahce systeM built April 1, � �—� °— — <br /> 1998,or later or for non-perfv mahce 5,ystems � <br /> loca�ed�n Shoreland or Wellh ad Protection Soil observatlon does not expire. Ptovious observations <br /> Areas or serving a food, bev�age or lodging by lw��ind�pendent parties are s�r�icient, uNess site <br /> �stablishment: conclltions hava been altered. <br /> t�oos tho system have a thre -foot verticaf <br /> separation distance from perl dically seturated <br /> soil or bedrock?"' _ , .._ Yes No <br /> For reduced separation dlsta ce systems(i.o., <br /> "performance"syatema under old 70$0.0179 or * Ma,y�be►�sduced by up to 15 percent if allowod in/oca/ <br /> Type IV or V system under ne 7080.2350 or orqlnanco. <br /> 7060.2�d0): <br /> Does the system meet the de igned ver#ical "'No sfand�id prolncol exists. This list is nof exheusG've, <br /> soparation distance from perl dically seturated !n SequenNal order, nordoes/tlndlcate which <br /> soil or bedrock?� combinaflons aro necossery to make thls <br /> ' �Yes No � detcnninr�flon. � <br /> Any"no"answer inddcates th t the sysfem is fafling to protoct <br /> ground weter. . <br /> Cerfiification <br /> Thls farm is io be completed nd attached to the Summary Form of the Minnosc►ta Polluifon Control Agancy's(MPCA)Complianca <br /> Inspection Fornn for�xls#In Subsurface Sewage Treatment$ystems. Obs�ervations, interpretations, and conclusfons must be <br /> completad by an inspector or lesigner, Completed form must be submilted to 1he Ic�cal unit of government wlthin 1 S days, <br /> Property owner name(s); ���,Q, C S <br /> ,,.�v. <br /> f�roperty address: __ x�� .Z L���_� —� -- . , _ <br /> .S,�SF.����.�.o��� O�OJ.lO_ <br /> Proporty owner's sddress(iF d( eront): � `� <br /> County: _.J-1¢L;L??�Pi?�, �`�'—�— , ' •�_ <br /> ..�.. ...—" Phone: �1.,.,�Zr���! � `7��. <br /> �heroby certify ll�sj/pe�sonell made rhe obsenr�fions, interpretallons, end con�clusions reported on Pl�ls fonn and thaf fhe a►� <br /> correct. y <br /> Name: _�-��� ��J- �fi.��.�YV " ��• � <br /> �`"' �"`— � ' .�'" -' � Certificatio <br /> 9usl ess �—`-- n number: (o�� <br /> n licenae nama end n ber. 5 r,c,,; �--�--. � <br /> ��..�'��.'����.���,�—�'�(,��� <br /> Name of IocQl unit of govermm �t• .—,�� or <br /> Signature: ���� `—'— -•—,— ,_ „ _ <br /> , �,..�., _ <br /> '� ---, Date: ^3 _�j=p� .. <br /> — ��----,� <br /> wq-wwisFs4•3 f <br /> d/1/08 Comp(lance Inspectio►�Form fn�FY��r;.,�ccr� <br />