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05/� 14:20 9528733112 PAGE 02I09 <br /> Parcel number; _ � System status: �ompHant � Noncompliant <br /> � (as determined�y this formJ <br /> 5oil Separatiort Compliance and Other Compllance <br /> Compliance Issue #3 of q � " <br /> Date of observation: J / (� Reason for observation: _ � _ <br /> This information on thrs form od es ot expir�. <br /> CompNarlce questionslC�iteria: (Required) VerifiCation Method": (Optional) <br /> Check th��ropriate box) (Check the appropriate 6ox) <br /> Far systems built priorto 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 ❑ Two previous veriflcations (att�ch boring Iogs) <br /> lodging establishment: <br /> ❑ Other: <br /> Does the system have at least a two-foot "' "" "� <br /> vertical separation dlstance from periodlcally . .�,� <br /> saturated soit or bedrock? Yes ❑ No <br /> For non-performance systems built Apnl 1, <br /> 1996,or later or for non-performance systems —""' -" � - � <br /> located in Shoreland or Wellhead Protection Sofl observaGon daes not expire, Previous observations <br /> Areas or serving a food, beverage or lodging by lwo independent parties are sufficient. unless site <br /> establishment: conditions have been altered. <br /> Does the system have a three-foot vertical <br /> separativn distance from periodicatly saturated <br /> soil or bedrock?' _ Yes ❑ No <br /> For reduced separation distance systems(i.e., <br /> "performance"systems under old 7080.0179 or " May be reduced by up to 15 pereent if allowed in loca! <br /> Type IV vr V system under new 7080. 2350 0� ordinance. <br /> 7080.2400): "No 5tandard protocol exrsPs. This list is not exhaustive, <br /> Does the system meet the designed vertical in sequentia!order, nor does if indicate which <br /> separation distance from periodically satu�ated combinatrons are necessary to make this <br /> ,sail ar bedrock7' .,_ Yes ❑ No determinst/on. <br /> Any"no"answer/nd�cates fhat fhe sysfem Is lailing to protect <br /> ground water. <br /> Certification <br /> This form is to be completed and attached to the Summary Form of the Min�esota Pollution Control Agency's (MPCA)Compliance <br /> Inspectlon Form for Existing Subsurtace Sewage Treatment Systems. Observations, inte�pretations, and oonclusions must be <br /> completed by an inspector or designer. Co pleted form must be submitted to the local unit of govemment within 15 days. <br /> Property owner name(s): � _ 5 , ..`--� ----•. --- . .^ __ <br /> Prqperty address: JQ�� _ ^_, l C�_.,..--,-.----- -._..._. <br /> Properry owne 's address(if different): <br /> —. .....,_.. _...... .... ,. _..._._ .__ <br /> County; _ 1�-- _._.. Phone: _,,, ----•, ..--�--- <br /> /hereby certify that 1 personally made the observations, inlerprefafions, and conclusions reported on fhis form and th�f they are <br /> correcL <br /> Nams; c�����'1(� _ _ Certification number: �1(�rj�_____ _ <br /> Business license name and number: ��j(� ���I(Q„� �l'1G _�� <br /> _,�. _.._... __ or <br /> Name of Ioc21 unit of o rnme . <br /> Signature: " ~ Date: ��-�--_� .__ -- — <br /> � , <br /> wq-wwists4•31 Compliance Inspe[fion Form for �xisCing SSTS <br /> 4l1l08 <br />