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07/08/2011 01:16 7634975011 SPTESTINGINC PAGE 07/09
<br /> Parcel number; __ _ _ _ System stetus: �Campllant �] Noncampliant
<br /> (es defe►minod by this fp►m)
<br /> Soli �e���t1o� Co�pllal��e and A�her Con�plpan�e-- Compliance Inspec6on Fvrm fior Existing SSTS
<br /> Compliance Issue #3 of 4
<br /> Date of observation: .._ Reason fol'observetion: ���{^.,_.f�c1�__`
<br /> _..___�Q' a:l,,7 01.1.-..--.-_.__. '�?3c+Tj ---
<br /> rhis lnformallon an fhis form do�s not expr►e.
<br /> Compllance questions/crl#erla: (Requlred) Verlfication Method"�: (Optional)
<br /> __�Cneck the„epprvpriefe box) __— (Check the epprop►�At�box)
<br /> For systems built prio�to Ap►il 1, 1996,and not � Conducted soil observetion(s)(attach boring logs)
<br /> loceted in Shorelgnd or Wellhead Ptotectlon
<br /> Are�or nat serving a food,b�verage or ❑ �wo pr�vfous veriflcations(attach boring logs)
<br /> lodgin�estebfishment �
<br /> C1 Other: ,..�lo.:,�..,.._..:�JJY•S 4,�0.7
<br /> Ddes the system have at Iceat�tw�-faat �, �o����L�—���-�
<br /> vertical sep�ration distance from periodically ,
<br /> satursted soil or bedrock? ,_.__ ❑Yes ❑ No � �,s
<br /> For ncrn-petfotmanca system�bullt April 1,
<br /> 1996,or I�ter or fo�nan-perfortnance sys'tems Sofl observation does not expire. Prevfous obseNeklons
<br /> located In Shoreland or Wellheqd PrbteCilon
<br /> Areas o�serving a food, beverage or lodging by tw�o independent partlea are euffiCiern, unlose slte
<br /> eSt3bliShmefrt: cnnditions have been altored.
<br /> Daes the system have a three-foot ver4lcal
<br /> seperation distance from poriodic�lly saturabed
<br /> _soll or bedrock?"__._.__.._ __�„ ...__. _, Yes [] No
<br /> For reduced separation�ist&ncg systems(i.e., • Me be reduced b u b 1�i eraent if sl/owed fn l�cal
<br /> perFormance systems under old 7090.0179 or Y Y P P
<br /> Type IV or V system under n�w 7080.2350 or ordlnance.
<br /> 7080.2400): *�No stendaM protvco!exisPs. Thls I1sP is not oxheustiva,
<br /> Does the system meet the designed v+�rtical in sequen6el order, nor does it indlcete wl�lch
<br /> sepe�ratlon distanee from perindicalty saturated cam6ina6ons a►e necessAry fi make this
<br /> soil or bedrock?* ❑Yes ❑ No de(erminaHon.
<br /> - —.�__.._.�...�.,,....... .__..-- �.........._._
<br /> Any"no"answ�r(ndlcates tht+t thE!systBm ia faNlnq(�n p►otect �
<br /> g►aulld wRiAr
<br /> Certification
<br /> This form is to be completed and attAched to the Summ�ry Form di the Mlnnesota Pollutfon Co rol AgeRcy's(MPCA)Compliance
<br /> Inspac6on Form for�xlsting Subsutface 8ewage Treatment Sysbem�.Observations, inte►�retatfons,and oonclusions must be
<br /> comple�ed by an inspector o�deslgner. Completed form must be submitted to tho local unit of governmerrt wlth►n 15 days,
<br /> Properry owner name(s): �/J_L1G 1__.N.��-1:� _.._- -..._ _.—.---••--- -----.___..
<br /> Prop�riyaddress� --1_3�?._O �/�-'�_�'1:�r..—��P_��-' '�� Cl�-c�f=4.,�_....- ---•-
<br /> Prope�i,y avmer's address(itdlt►eranq: _�_.�.._...,.---...--.- -.--.,..,.,._------- -- —.
<br /> county� --���1,��- Properly vwner phono: ��?�.^-- .;Q�O _,.... _
<br /> 1.��,--_..�. "�.•
<br /> I hereby ce�rtify fhat I peraonally mede t�he abserveHons, inte►pret��+ons; and concluaions►eported on this l,orm end fhe�they a►e
<br /> conecr.
<br /> Namo• �(''.�..C�,.��. SG.1:�1'��__�.�,.'S-- ,._ Certiflcetl�n nutrber lo_��„,.__ _..._ --
<br /> Business Ilcense name and number: S-4''1��`S�lbL1,�I.�,t.G_i—L_1_C%�3�I-'-������.3�°�C-`Z:��-�� . ur
<br /> Name of local nit of govemm�nt: _ ��� .....____.._._ —�,.••_- -.••.,.,..�_
<br /> Signature: �i-c'"��--�-6�� —�=�-�-w�. __��,._._.,._. ..._ Dale: _�a�3 O �a0 �__..._
<br /> �,.. -
<br /> . Ann•h57:.,.....: —.. _..� — .,...•--- _:... ---�.�
<br /> ..._.......�.,.,.,....„� aa�.�cti•R�nn �T ,38fi4 • TTY 651-282-9332 or 800•657-3Bfr4 • Availablc 1n ultcmaNve fqrtil�ls
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