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Paroel numbEr � __ Systern status: � Compliant ❑Noncomp{i€�nt
<br /> ,_._ . „ - (as cletermined by fhis fann)
<br /> �a�l s�p�rrafiom� �oimpliance and O�:her Com�li��tce
<br /> Compliance Issue� #� t�f 4
<br /> p�t�vf observatlon: 5 Yl.,�0`tC ,__ P.easort far obseYUAtlon: �''"�L�'�'�'"'�...__ �'�' ��'�-
<br /> Thrs;nformation dn thls fonn does not expir'p.
<br /> Coanp{i��7ce questio�s/cr�teri�: {Raquired) Verlficatpon IMllethoc#'""^. (Optional)
<br /> _(Chec!<(fiae appropriafe box��_ ,„,._ (�neck fha approprlate la�x)
<br /> �or syslems built prior to April 1, 1996,and nol � ConduotecS soil observation(s) (attach borfng logs}
<br /> located in Shoreland or W�ilhead Protaction
<br /> Are�or na#serving a fo�d, bever�ge ar � �"wo prevlous verific�tions(�t#ach borinq logs)
<br /> lodging ost�blishmen�: ❑ Qther: ����C1�"r,:'����'�:����'�'�'�
<br /> �oos the system h�ve at least a lwo-ioot 7�'� �,^'� ��"��rti�'*.,�.ry.,,,,.w,�,w, w,
<br /> vertical separation dist�nce Cram periodically ,�
<br /> saturated soil_.or bedroafc^ �]Y�s,.,❑ No -{��-4,1�'�,,,;�r� ra a�.�o�L
<br /> ...__ __ ,,.�.. ��
<br /> �ar non-performance systems built April 1, 3�.��q�'�a��_"��-��A`�
<br /> 1996,ar laler ar for non-performance systvms 'p' °�' �`4`-�'�'`t""`�'� '��"'� �
<br /> located fn Shorel�nd or Wellh�ad Protec#ian Soil obsorvailon does�not explre. Pre�ious absen,ations
<br /> �lreas or senring a fbod, heuerage ar loclging by iw�7 independent parties�re s�sffic.ient, unlass site
<br /> estahlishmErt'
<br /> condi�ions heve been al#ered.
<br /> Does the systom h�ve a ihre�-faot verlical
<br /> separation distance from pariadically sakurated
<br /> soil,or bedrock?* _ _ �, �!Yes N�
<br /> Far reduced separa#ion distanae sys#ems(f.e.,
<br /> "performancc"systems under ald 7080.0179 or " May be��educed by up to i 5 percenl if allowed in local
<br /> Ty�e IV or V sy�tem uncler new 7080.235p or ordinanG4.
<br /> 7080.7_400): **No sfarnlard pmtocol exists. Thls lfst!s not exhausNve,
<br /> Daes ihe system meet tl�e design�d verlical !n s�equenti�l orrler, nor does it tndlcafe whlch
<br /> separation distance irom periodioally satur�ted con�binatians�►�necessary to meke this
<br /> soil or hedrock?" � Y�s No detarminat;on.
<br /> Any""r�n"answer ind6cates�/1at the systerr�As faJlfny�to prot�aat '
<br /> yround water.
<br /> Certificat�o�
<br /> 7his Fbrm is to be completed and �ttacheci ta tho Swnmary Form of the MinnesC�t3�Pallutian Control Agoncy's(MPCA) CompliancB
<br /> Inspectlor� Form for Existing Sub�ur�aca Sewage T�reatment Syst�ms.Obs2rvatinns,interprvtations,end cancluslons must be
<br /> completed by en inspector or designer.Completed fc�rm must�e submlttetl to ttie local unik of government within 15 days.
<br /> Property owner name(s): ������1`��1r1�'`�Y,,,,,, �, __
<br /> PrapQrty�ddress: � }�S '�1_L� �'��'£�'r"-�'7�i�.7��—.�+��-��_-
<br /> Propohy owner's address (If dii�erent): ___�..__ .�---- ._�.---- ._,.,--�--
<br /> �OLllltY: �}�1,�.��.,�_ _....� �IiPf�a: �J..�..-•-Lr��� .'_ L��l-�----
<br /> !hProb}�cert;fy thaf•!personally mar�e t,hQ�6sen�ations, interpretafions, and con�el�rsfa�s r�l�atecl on this form end flaet fhey are
<br /> CnrreCf_
<br /> �r � �^� Certiflcation n��m4�er: f
<br /> Name: � l'�l/'�-1.�--_iJ.,:._.���1-�\"��✓1_'�'�-;•� _ --- —���' ��)
<br /> ..._>_ ._. _ _........_._
<br /> �lusiness license name and numbcr. S��C '��",'""��?•1�_..��1;�_�,� "� ��_�'�lo_T,�.�W'��_'.°a ln��,. _ or
<br /> Namo of local unik of government:
<br /> .,,__.^
<br /> —�•----
<br /> Signature: �. � .._�---- -� _..._.___ Date: �r'1 r��---...LL
<br /> wq-wwisrs4-31 Campl�ance lnspectron Farm�or Exrsting SSTS
<br /> .r�rioR
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