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06/08/2010 23:37 7634975011 SPTESTINGINC PAGE 09/13
<br /> Parcel numh�r; __,_ _._,__,_,._,,,,,,, ,,, ,,,, ,_ ...._.._.__ _ Sy5lem slal:us; � �Cornpllant ❑ Noncomplianl
<br /> ........ . ... _.... _
<br /> � (as delermined by(his (r+rmJ .
<br /> Soil Sepa�ratian Gonrapliattce and O�her Compli��ce -- Compli�nce Insp�cfion Form for Existing SS7S
<br /> Compliance Issue #3 of �4 �
<br /> Date�F ohserv�tlon: _, �'-►�)��pJv RaAgon for obFervatlon_�i�S�voy'�►,�,, Q�Yv1�_ _
<br /> This lnfprmetion on Ihls(��m d0es nol expire.
<br /> Compliancc questio�slcriteria: (RoquirQd) �/erification Method*": (Optlonal)
<br /> Checlr tl�c��� risle box� �_ _._ ,,,, _ (Chech(he approprlalr hoxJ �
<br /> For systems bullt prior to A�,ril 1, 1998, and nol I � Conductod soil Ql�servation(s)(eltach k�oring logs)
<br /> locatod iri Shoreland ar Wollheac! ProlecNon �
<br /> Area or nol serving a foocf, beverage or � ❑ Two provious verific�ations(aftach horing logs)
<br /> lodging esteblishment: � ►
<br /> � o�n��: ..3,,� a 3 -� s��w��_o��...�
<br /> �oes tho syslem liave at IQast a kwo-foot
<br /> vert{cal sop�ration cllslence from periodical�y - �• ----.�.—
<br /> _saturaled soil or bedrocic? �Yes No
<br /> __.. .�.- ------�., �.�__._,�
<br /> �or n�n-perForm�nce syslems built April 1,
<br /> 1998,or laler or for nan-pertormance syslems � ` �'"'--'""—�'� --
<br /> located in Sl�orel�nd or Wellhoad protecflon Soll c,t�servaClon cloes not explre. Provious uUsorvallons
<br /> Areas o�s�rving a food, beverage�r lodging by lwo Indepcndenl�arlfes are suffcient, �.,��less slte
<br /> establishmenL' condikipns have beon alterQd,
<br /> Does tho system have a threa-ic�ot.verUr,al
<br /> sepaf2flon distanCr frpm periodlcally s�tur7lcd �
<br /> _soil or bedrocic7' ___,,,, _�_Yos__ � No � ,
<br /> For reducecl separatlon distance syslems�(I.e,, .
<br /> "periormanr,e" syslems under�Id 7080,0179 or y May be roduced by up l0 15 percent i(allc�wed!n local
<br /> Typa IV or V system under new 7080. 2350 or or�1/nan.r.e. ,
<br /> � �0B0.7�°o�; � , "No stondard profocol exlsts. This list is not exhausllv�a,
<br /> Does lf�e syskem meet the clesigned vertical �n s�qi�entlal order, nor does!t indicate whlrh
<br /> sepAretion distanr,e from periodically satureted r,omhina!lons aro nocessary to make fhls
<br /> _soil or bedrock7' _.____� ❑Yes _No doferminaiion.
<br /> Any "no"answer inHicates thaf t/�e system fs fai!!ng to pr•otect
<br /> ground water.
<br /> Certi�fication
<br /> 't�his Form Is to be r,.om�leled and afl�ched lo lhe Summary Form of Ihe Minnosota Pollutfon Control;�gency's(MPCA)Com�llanco
<br /> Inspectlon Form for Existing SubstirFace Sewa�e Treatment 5ystems. Observafions, Intorpretaklans,and cancluslons must be
<br /> c�mnleled by an.ins��ctar or cleslgner.Completcd form musl be submittod to the local unit oF govemment within 15 days_
<br /> Pmpc�rty owner name(s): CJ��/�.� ��L.�_���.:,�� ._.__... ..�.�.._.�..._...,_ w �. , ,.._
<br /> -.•-
<br /> f-'r��erly address: 7 I O L� ��J�-4�„�_p�_}1.�� _._.._..,.,_...,__...,,,�..._....—_ ..� ....�—
<br /> I'roperty owner's addraSs(If.cilffer�nl): _, ,,, � � „ru., _ „^__
<br /> GountY: ���_�,�J� Pr��o�ty owner phone: �� -ta,7•le -��'�_, ..�,_
<br /> I hereby ccrtify that I persenally m�de rho obsorvations, In(er�retafions, �nd conclusions roportod on fhis form and fl�a[they are
<br /> correct. •
<br /> NamP: „�r,_-�`�.r-.��y.1�,.,�•,"�(,�l��h��� __...,_ Cortiflcal.lon number. (�, �� ,._�.
<br /> 8uslness license namc�ncl number: ���j�,.�\�_��1„1C,�• 1.1(�,�`.,3p1;��'}Sz3-49�—�.5_ln.tr,�__,,._ vr
<br /> Name of local unil of govcarnment' •
<br /> Signatu�e: �� __�.,,, ,��� ^_� _.... �, .- Drate: _ - a0 -a��p � �.
<br /> www.pca,stale.mn.u5 � • 651•Z9(r-G9oQ • 800-657-366q • TTY 65�-z6Z•533Z or.a001657•3864 � Av�ilable in alrernariva rnrmar�
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