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01/31/2612 14:31 9528733112 PAGE 05/06 <br /> Parcel number: ___ __ � `�_ System status: f�Compliant ❑Npncompli2ni <br /> (as determined by7his formJ <br /> Soil Separat�on Compliance a�d Other Compliance <br /> tampliance issue #3 of 4 � <br /> Date of observation: � Reason for observation: ' � <br /> rm n ' � <br /> Thrs info at�on o th�s font�does not expire, <br /> Compliance questionslcriteria: (Required) Verification Method*": (Optional) <br /> (Check fhe a�propriate box (Check the appropriate boxJ <br /> For systems bu�lt prior to April 1, 1996, and�ot �Conducted soil obseroation(s)(attach boring logs} <br /> located in Shoreland or Welihead Protection <br /> Area or not serving a food, beverage or ❑ Two previous verificatio�n,,�( ttach boring logs} <br /> lodging establishment: � _ �r�,\ Ib7; � ���J <br /> Other. � <br /> Does the system have at least a two-foot �3� '� - �� <br /> vertical separation distance from periodically � <br /> saturated soil or bedrock? [LYes ❑ No /fjt� <br /> For non-performance systems buflt April .1, <br /> 1996,or later or for non-perto�mance systems �"'��'" """ <br /> located in Shoreland or Wellhead Protection Soil observaGon does not expire. Previous observations <br /> Areas or serving a food, beverago or lodging by two independent parties are sufficient, unless site <br /> establishment: conditions have boen altered. <br /> Does the system have a three-faot vertical <br /> separation distance fram periodically saturated <br /> soil or bedrock?` Yes ❑ 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 locel <br /> Type IV or V system under new 7080. 2350 or ordinance. <br /> 7060.2400)� **No standard protoco!�xists. This Irst is not exhaustive, <br /> Does the system moet the designed vertfca! in soqusntia!order, nor does it indicate which <br /> separation disYance fram periodically saturated combinations are necessary to make thrs <br /> soil or bedrock?' Yes ❑ No detBrminativn, <br /> Any"no"answer iadicates that the system Is failing to protect <br /> ground wafer. <br /> Certification � <br /> This forrn is to be completed and attached to the Summary Form of the Minnesota Pollutlon Control Agency's (MPCA) Compliance <br /> Inspection Form for Existirtg Subsurface Sewage 7reatment Systems. Obseroations,interpret2tions, and conclusions must be <br /> completed by an inspector or designer. Completed fOrm must be submitted to the 1oc21 unit of govemment within 15 days. <br /> Property owner name(s): L.�1�`� 1� �1��Y._..._, ..r.�.- ----� ---....--------... <br /> Propertyaddress: ����Q� � �� ^ � _ . _.___. <br /> Propet'ty owner's address (i4 different?: ___,„ ,,,,,,,,_„ � , <br /> � ...... . _.._. .__-----•-._._._...._.. --- <br /> Couniy: _ �{� w.r. Phone: --- ---._.. . ... .. <br /> !hereby certify that�persona!!y made the observatlons, Interprelalions, and conclusions rc�ported on�his form and rh�t they are <br /> com:ct , <br /> Name: �'�p�,���1� __ Certifcation number: �((��j�___ <br /> Business license name and numbe�: , 1 ` �t�� __�_ or <br /> Name of local uni ove ent <br /> Signature: , _ _ Oate: ____ _ <br /> wq-wwists4•31 Complionce Insvection Form far Exi5ff�1Q SSTS <br />