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11/0512010 03:55 7634975011 SPTESTINGINC PAGE 09/10
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<br /> Parcol number: ______.__._ „ System status: � Compliant [�NoncompNant
<br /> (as d9termined by thls form)
<br /> SoO� Se��ara#Gon �ormpliartt�e and �Other Com�plpan�e� Compliance Inspection rorm forExisting SSTS�
<br /> Compliar�ce Issue #3 ofi � �
<br /> Date of observation; �� -�,o � _ Reason for�bservation: .�z_ _
<br /> 'F����..----�---.,.�
<br /> Tliis infom�stlon on thr's fonn does not expir�e.
<br /> Compliance questions/criteroa: (Required) Verification Allelhod'': (Optionaq
<br /> (Checlr the s_ppmpriate 6o�t)__ _ .__ . (Check the appropriat�box)
<br /> For systems built prlor to qp�il 1, 19�6, and not � Conducted soil observatlon(s) (ettach borinq logs)
<br /> Iocat�ed in Shoreland or Welihead Protection
<br /> /�rea o�not senring a food, beverage or �1 Two previoias vorificatinns(attach boring logs)
<br /> lodgln�establishment: ❑ Other: 3��.��)�7�p,_,_.,,,.,,_
<br /> l7oes the system have at least a two-faot �� ���� '
<br /> vartical separation distance from periodlcaliy --------• -•- -- �.,--
<br /> saturated s�il or hedrock9 �Yes No '.� J
<br /> „ ._ ._
<br /> ..-----..
<br /> ._..------..........__.. ........._....._._..... .,. ---
<br /> For non-perFo�manr,e syslems built April 1, ,
<br /> 1996,�r late�or for non-performance systems Soil observation does not ex ire.Prevlous obs�rvations
<br /> locared in Shoreland or Wellhead Prolectlon ►��
<br /> Areas or serving a food, beverage or lodging by iwo independent pertfes are sufFlclent, unless site '
<br /> establishment= conditions have been altered. ,
<br /> �o�s the system have a three-foot vertical ;
<br /> separation distanc�from periodically satureted �
<br /> soil or bedrocic?° �Yes ❑ No
<br /> For reduced separation clistance systems (i.�.,
<br /> "perf4rmance"systems under old 7080.D179 or ` May be r�duced by up to 15 per�;ant if�llowed(n lor,al ,
<br /> 7ypo IV or V system under ne�nr i080.2350 or o►v,�inance. ;
<br /> 70B0.2400): `°No stand�rcl pro(ocol exlsts. Thls l�st is not exltacrstive,
<br /> Does the system meet lhe deslgned vertical !n saqr,►ential order, nar does!t indicale whlch
<br /> separation dist�nce from periodically saturated combinafions are necsss�ry�a make#his
<br /> soil o�bedr�cic?" ____D,Yes_ ❑ No defennlnetlon.
<br /> .---._.__........,..__.,,..,:,.......---
<br /> Any"no"answer indicat�that the system is te�iling fio protect i
<br /> ground water. �
<br /> Certif�cafiion
<br /> �
<br /> 7his form Is to be completed and altached to the Summary Form of the Minnesota f�ollution Control Agency's(MPC/�1)Compliance
<br /> Ins�2ctlon�orm for Exlsting Subswrface Sewage Treatment Systems. Obsen�atians,interpretations,and conclusions must be
<br /> completed I�y an inspector or deslgner.Completecl form must be aubmftted lo Ihe local unit oF government wlthln 15 days. ,
<br /> Pro ort a�roner name s �(a- �
<br /> P Y ( )� ._N._1t1��y►4.�;II.._.?sSQ.r�1__.,..,.,.....
<br /> ...___ .---_..-- --.......
<br /> .--�
<br /> Property adclress; 2,'a,$c7�_�s�t_ L��rC���LSZw� �Q�c�� .._ ..., I
<br /> I'roperty owner's address(if different): _ `
<br /> County; __I-��✓1-5.���i 1_1��__ I'roper#y c7wner phone: ,l�12�.�!"t_?_r I...a�.�C_.., . ..,,._-1
<br /> I/�ereby cerfJfy the(1 person�lly mt�de the observetlons, ln�rprc�tefions, and r,vnclusions r�ported an this for�n and tl�at they ara �
<br /> correct. ;
<br /> i
<br /> . '
<br /> Name: �'����1-��,—SC.1-11.�'����'� —,.._. ..,..,.,..._. Ce�tificaiion number: ��� .__... .__ �
<br /> I�usiness license name andnumber. • �•�c ��r '' . ` '�V � �
<br /> ��:����,llz��l_C��_1�.1l�� , `� '��r T� '7,ia;3-�V��'1,.--��s,� �
<br /> . _��_.._.... ........... .._. .....,.... ,.,. , �
<br /> Neme af locel u it of govarnment: j
<br /> � _._._.............,-- - -- �----...,,,._ ..�
<br /> slgnature: 'Uj• �� ----�------- pate: _►__I— �1__a�)J ,_..�
<br /> �
<br /> , ,. . .,,...,._.._,.....,.....,,. , . . ,.,..._. ,_._.� ....
<br /> wWw.pca.state.mn.us � b51�29G-6300 � 800-657-38b4 • TTY 651-282-5332�r�nn-�S�-�R�� . Av�ilahlP in all�Pmati��A fnrmoae
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