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Parcel number _ System status: � ❑ Compliant � Noncompliant <br /> -— _ _ -- — <br /> (as determined by this form) <br /> Soil Separation Compliance and Other Compliance - Compliance Inspection Form for Existing SSTS <br /> Compliance Issue #3 of 4 <br /> Date of observation: _�--) p -U^,� _ _ Reason for observation:_�'�y''�'.�-,�� <br /> . -'S rl s-�<�(%g___ <br /> This information on Ihis/orm does not expire. - - — <br /> Compliance questions/criteria: (Required) Verification Method'*: (Oplional) <br /> Check the approprrate box) _____ Check the a ro riate box <br /> ---- --T ---- ( PP P ) <br /> For systems built prior io April 1, 1996, and nol I <br /> located in Shoreland or Wellhead Proteclion � � Conducted soil observation(s)(attach boring logs) <br /> Area or not serving a food, beverage or � ❑ Two previous verificalions(attach boring logs) <br /> lodginy establisl�ment: <br /> ❑ Olher. bo'F'CDwI '(�7��'}�c.1���- "�o��it7'',�.,�i <br /> Does the syslem have at least a two-foot - <br /> vertical separation distance from periodically `-r'`�'"'-1 b '`5 <br /> _saturated soil or bedrock? ❑ Yes ❑ No __ �p-�-(L4:a �,o��. �,��,�� �,��.����M��<>) <br /> For non-performance systems built April 1, .� ���1 ,�� �p i! <br /> 1996, or later or for non-performance systems - ----- <br /> located in Shoreland or Wellhead Protection Soil observation does not expire. Previous observations <br /> Areas or serving a food, beverage or lodging by two independent parties are sufficient, unless site <br /> eslablishment: conditions have been altered. <br /> Does the system have a three-foot vertical <br /> separation distance from periodically saturated <br /> soil or bedrock?' ❑ Yes [�9]No <br /> For reduced separation distance systems(i.e., <br /> "performance" systems under old 7080.0179 or ' May be reduced by up to 15 percent if allowed in local <br /> Type IV or V system under new 70II0. 2350 or ordinance. <br /> 7080.2400): "'No s(andard protocol exists. Thrs lrst rs not exl�austive, <br /> Does the system meet the designed vertical in sequential order, nor does it indicate whicli <br /> separation distance irom periodically saturated combinations are necessary to make this <br /> _soil or bedrock?" _ ❑ Yes ❑ No determination. <br /> Any "no"answe�indicates t/iat tlie system is failing to protect <br /> ground water. <br /> Certification <br /> lliis form is to be completed and attached to the Summary Form of the Minnesola Pollution Control Agency's (MPCA) Compliance <br /> Inspection Form for Existing Subsurface Sewage Treatment Systems. Observations, interpretations, and conclusions must be <br /> completed by an inspecior or designer. Completed form must be sut�mitted to the local unit of govemment within 15 days. <br /> Property owner name(s): ��v#, q� �'a9.)�1 L04�t.�i D i�� <br /> Property address: _ a �: S� '���F�}i.�1�, �.�Y�� '�T���Z_�_D�t91,`�(� - -- <br /> � <br /> Property owner's address(ii difterenq: <br /> County: �k;.%}�t��•,,'t !.1 ----_ Property owner phone: `�'? �Z-?-,`-}�)�- �'��"1 f.-� <br /> 1 hereby certify tha(1 personafly made the o6servations, inferpretations, and conclusions reporfed on this form and that they are <br /> correct <br /> Name: �-(��/��� �, �j���¢�.��x�c� Certification number. ___�a,� <br /> Business license name and number. �-�Q-�{i����l� 11JL� L.1 C�_�_��3 - �}9 7 _ 3 S(o(�, or <br /> Name of local nit oi gover�ent: <br /> Signature: �� � [y-�(� - ��------ Dale: �-) 1��oj <br /> �— <br /> www.pca.state.mn.us - 651-29(s-{r300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in atternative formats <br /> wq-wH-rsts4-31 • 4/10/09 �= Page 4 of 8 <br />