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08/1812010 01:20 7634975011 SPTESTINGINC PAGE 65J68
<br /> Parcel number. ... ,.,,.,,^.,,.....,,._,.__ Sysiem slalus �Compliant [I Noncompll�nt
<br /> ��"� (es dete►m(ned by this form)
<br /> So�M 5e�a�atpon C�rnpllance and Other Compllance � Cvmpliance Inspection �orm t'or Existing SSTS
<br /> Compliance �ssue �3 of 4
<br /> Date of ohsen�aUon: ��^ S- a�?�_0 RpaRon far observalion:'Q��Qc^'��'("� '�'�1(�}t���__,,,,,_
<br /> This lnformetlon on tlils fnrm dves not explre.
<br /> Cornpliarnce questlons/criteria: (Required) Verificatlon Ma#hnd"": (Optional)
<br /> (Checl�tho appmpriate box) ,�_, (Cl�eck Ihe eppropriate box)
<br /> Far systems built prior to Aprll 1, 1996,and not � Conductcd soil observatlon(s) (aitach bo�ing logs)
<br /> located In Shareland or Wellhead Prolecl,ion
<br /> Arpa or not serving a food,beverago or ❑ Two previous verlflcetlons (attach boring logs)
<br /> lodging establlahment: [] Olher: 3,2�,,,�:������Y�j�Q�.
<br /> Does ll�e systQm hsve at I�east a lwo-Foot
<br /> vertical separaiion distance irom �eriodically -"' - "'—„"„'—�`—
<br /> satureted soil or bedrock? ,:. �_Yos _ No . ., _, ,-•--
<br /> Fo�non-porformance systPms bulll April 1, _,,,,�_
<br /> 1996, or later nr ior non-perfarmancA systems Soll observaUvn doos nnt explre. Prevlous ob�ervations
<br /> located In Shoreland or Wellhead Protecllon by twA independont palties are sufficlenl,unless sike
<br /> Are�s or serving a food, beverage or lodging
<br /> ostablishmenl: condilions have been allered,
<br /> Does ihe system liavo a ihroe-fioot vertical
<br /> seperation distance from periodlc�lly setu�al.ed
<br /> soil or bedrocic7' �., . _ ,�,�Yos No
<br /> For rQduced separation distance syslems(i.e.,
<br /> "performance"systems under old 7U80.0179 or ' May be�duced by up fo 15 parcent if allowed in local
<br /> Type IV or V system under new 7080. 2350 or oncllnAnce.
<br /> 7080.2400)_ �"Nn standarrJ proloco/exists. Thls list is not exheustive,
<br /> does the system rneet the designed verlical In sequenfial orcler, nor dvos it indicatv which
<br /> separation clista�ce from F�eriodicelly Faturated comGin�tions erQ necessAry(r�melce thls
<br /> ,�oil,or badrocic?' _ � Yes ❑ No deto►i'nln�t�on.
<br /> Any"no"answer!nd/catas tlyat the s}rsF,em is fa/ling to protect
<br /> ground wat�r_
<br /> Certificatio�
<br /> This form is to be completed and atkached to the Summary Form.of the Mlnnesota Pollulion Control Agency's (MPCA)Complianc�
<br /> fnspectloro Form fo�Existing SubsurFace Sewage Treatment Systems.Observations, inlerpretallons,aiid co�cl�asions must be
<br /> compteted by an inspocior or deslgner. Completed form muet be submilted lo tho local unit of gove�nment withi� 15 days,
<br /> Properly own�r n�me(s): �o i�1.111��„�..N L�[1�,t' ...�......„ �,.,,_._,._.— —..,_.. _
<br /> Properly address' ���-1�_�i_������,.._"�..�,."�.._.��� � , l7'e�9���._,�--- -----_.,,
<br /> Prope�ty ownor's�ddr�ss(if dlfiorent): _..,,-,..-
<br /> ,_.:.....,.... ----_,._
<br /> CountY: __I�:,(�.�'..���� � ,,._._._ F'ropert�r owner phone: �,.�j_S?i.�.t� ��lo��
<br /> 1 heroby certify that 1 pe�sonally mede tho observat/ons, �nterpretetlons, And c�nclusinns►�ported on this form an�i lhat they a��e
<br /> correcl.
<br /> Name: .._,��`.�/Y�_�1�\_�� SC.�����i Certification number. �(���) ,,,�
<br /> Buslnass Ifc�nsQ name and number_ �=j=���'�.��4� l�l.Ll_L,1,_��.��,G%.�+r„-���....4�-. �'� 3 "�`a��w1�'L��_, or
<br /> Name oP local unit of govemment• __�,_�_�,��,_ _.�.,,__. __
<br /> Signature: � _��,,_�-�_�— Dala: � =°°j- a_52.11.? �.�_..,,.
<br /> _..._,..._------• —.,,._ _�..........�---....,:_........-_•.•--- ..,,..
<br /> www.pca.5���e.mn.us • 651-296-6300 � 000-657-3Bb4 • '1?Y 651-282-5332 or 800-657-386� • AvallaUle In alremative formals
<br /> ..._.....���.i �� . •i��inn n......i..en
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