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11/02/2010 21: 25 7634975011 SPTESTINGINC PAGE 06/09
<br /> Parcel nuri�or; � _, _ ` _ Syst�m staius:
<br /> . ----.. I� Cam liant
<br /> - P ❑Noncompliant
<br /> (es�I�lermfned by Ihls ionn)
<br /> Soll Sepa�atpan Co�rn�lianc;e an�d Other Compl��ance- Compliance Inspection l=orm forExisiinq SSTS
<br /> Compliance Issue �3 0� �
<br /> Date of obsen►atlon: � ��y��p��_ Re�son for ohRervation;
<br /> -�o��.�-►-�'f�u�l ,
<br /> 7'his lr�fonnepon on fhis forrn doos noF expire. - -��-�---.—.
<br /> Co��pliarnce questioro�/�srite�rla: (Rec�iUred) Verificatior� Method*":
<br /> CheClc the a_ �o riate box (Optional)
<br /> --1.—_..PP_P .�.._ - -- ,.— (Chec/r Ihe a
<br /> For syslems bullt prior tp�prll 1, 199(i, end not pP�pNatQ(�ox)
<br /> located in ahorel�nd or Wellhead Protactlon �I Conducteci soil obsenration(s) (atl�ech boring logs)
<br /> Aroa or no1 serving�food,bev�rage ar ❑ Two previous voriflcations(ariach boring logs}
<br /> lodging establishment:
<br /> ❑ Oihe�; � �
<br /> Does 1he systQm have at least�lwo-foot -01 � '�' ��=� �'��__��'�1 pJ.t_
<br /> v�rtical separation dlstance From perlodically ��,�������.LV,�i��V��
<br /> sa#urated soil or bedrock? _ [�(('Yes No
<br /> ._,._ _.__
<br /> . �A 11...�__„
<br /> For non-per�ormance systems buill April 1, -- •-
<br /> 1�98, or later or for non-performance systems ^ � - � ,_
<br /> located In Sl�oreland or Wellhead Pro#ecllon Soil observailon does not explre. P�evious observakions
<br /> Areas or senring �food, beverage or lodging by two independ�nt parties ere sufficient, unloss site
<br /> establlahm�nl:; conditions have been altered.
<br /> Does the system h�ve a 11uee-fo�(vertical
<br /> sepa�allon distance from perlod(cally saturated
<br /> _ soil or bedroc{c7° _ Y�q
<br /> - No_...... ----
<br /> For reduced soparation cllstance systems(f.e., ^
<br /> "perFormance"systems under old 7080.017g or ' Msy be roduced by up to 95pe�rcQnr 1lallowed in loc�l
<br /> TypQ I\!or V�3ystem under neW 708p.235�or old/nance.
<br /> 7080.2400):
<br /> Does ihe system meel the desl necl v�rtical "'No sfanda�i proMcol exlsts_ Thls list is not exhat�stivo,
<br /> g n sequentlA/order, nar does i!indlcato wlilch
<br /> sep�ration dlstance f�om periodically satural�d com6inati�ns er�ner,essary to mako ti►is
<br /> soil or bedrocic?" ._ , ._ _�]Yes [�No doterminallon.
<br /> ^Any��no"answar Indicates thet thP systom is failing tn protect
<br /> ,qround waler.
<br /> Cerfiif�a�t�on
<br /> This form i,,to be completed and attached to the Summary�orm of the Minnesota Polll,tion Control Agency's (MPCA)Cor�np��ance
<br /> Inspectloro Form for I�xlstRng 3�ubsurFace Sewage Treatment Systems.Obaervatiohs, inte�pretations, and conclusions must be
<br /> c�mploted by an inspoctn�or de�igner. Completed form must be submllted !o Ihe local unit of government within 15 days.
<br /> I�roneriy oNmer name(s): ���vyt�.�j�c ��/�, y. _�,���
<br /> Property addr�ss: __.S Z�� _.J�O ._.._...:!'.�����'�r��OAb...�—�-���(7 � -w,.---.... ., .—,.--
<br /> Property o�nrnor's�ddross QF differe�q� � ' — '—� �-
<br /> . _.,... _,.
<br /> Count - _..,. _.,
<br /> Y� _. _�'-��1`�-.����I.S _. _ Properly owner phone: p� - ,. � ...—,.—.�
<br /> —_. __ —._�_2___�.u�-F..,_-1a�.� _ --
<br /> 1 hareb��corflty fhal I personal/y m�de the o6se►vAtions, /nferprefafions, end conelusi�ns reported on this 1`orm and th��t/�Qy1A�
<br /> comacf.
<br /> Name_ �1��IS=.1,.�—�Li_.. �L�-�1}�'��^i'w�j �
<br /> __.�__._ .,.,„ Cerlificatlon�umber: �
<br /> — ��.. —...__,.--`
<br /> Elusin�ss liconse name and numLier_ _�,� -Q ^��y�_i I�.l�����,�_,���`�1� �c'L�'�;�tir� " �.c, r ,
<br /> - — 7t2,5',.._VJ_�_��:as�.l,�__ or
<br /> Neme of local ianit of governm�snt: '�
<br /> � ....- -�
<br /> - .,. ..... .,_
<br /> . . ., .......
<br /> Signature: �� -.: --... _.. •---�---
<br /> �..
<br /> - � . • ��•--_.,_ „ _.... Dalc: _� -a�,:�s�oJ..0 -- ._
<br /> ..----� . ., ..,.. --- ..
<br /> - -�---.,. _...,_
<br /> www.pr„a.state.mn.us • 651•296-6300 • 000•657-386q . � .
<br /> wq-wwlsts4-31 � 4/z4/09 _......_ . _. .,. ..._^-_�"-
<br /> TfY 6�1 ZB2•5337.or 800•657-3861 Available In altemakive format�,
<br />
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