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07/2812098 01:26 7634975011 SPTESTINGINC PAGE 64105 <br /> . <br /> Parcel�umber. ,,.,,w,, System stetus: []Compliant ❑Noncvmpllant <br /> (as dete►mined by thfs fnrm) ' <br /> Soil Separatiort� Compliance and Other Go�mpliance� <br /> Compliance Issue #3 of �4 . <br /> Date of observation: � Reeson for observalion: <br /> Tliis lnforn►aflon on this fiorm does not expire. ��� �~ <br /> � Compliance questions/crite�ia: (Requlred) Verificatlon IIM�thod'": (Optlonal) <br /> _� CheG�thQ a ro ►iate box _,,,,_,..� (Check the appmprfete box) <br /> For systems built priorto A�r�l 1, 1996,and not � Conducted soil observation(s)(etiach boring logs) <br /> Iocated In SNoreland or Wcllhead Protection <br /> l�roa or not senring a food,beverage or ❑ Two prevlo�us ve�'rtfic fio s r�boring logs) <br /> Iodging establishmenl: ❑ Dther: MnukC1�� Sc�� `� � <br /> Does the system havQ at least a lwo-foot �� �.��L�,� A� <br /> vertical separatlon distance from pe�iodlcally ��--'� �a�2 <br /> saturated soil or bedrock? [�Yes ❑ No ,,,�0_ _S�1�C�Oi.I �f0 4�� ;�_� <br /> For nan-perfvrtnance systems built April 1, <br /> 1996,vr late�or for non-perEorman�e systems ' <br /> located in Shoreland or Wellhead Protection �Soii observatfon does not expire. Previous observatfons <br /> �reas or serving a food, beverage or lodging by iwo independent parties are sufficient,unless slte <br /> esteblishment: conditions have�been altered. <br /> Does the system I�ave a three-fo�t vertical <br /> separation distance from perlodiGally saturated <br /> soil or bedrock7` • Yes ,. Ne <br /> For reduced separation distance systems(I.e., � <br /> "perFormance"systems under old ib80.0179 or ' May be reduced by up to 15 per�ent if aUawed ln loca! <br /> Type IV or V sysiem under new 7080.2350 or ' oMlnance. <br /> 7080.2400): "*No sfandard protocol exists. This llst�s not exheustive, <br /> Does the system meet the designed v�rlical in sequentleJ or�der,nor do�,s if indicete which <br /> separetion distance from perlodically saturated combinations are necessary tn mahe fhis • <br /> soil a�bedrock?" Yes No det�imination. <br /> Any"no"answer indicAtes fhet the syst2m is falifng iio prote�t • <br /> ground wat�; <br /> Certification <br /> 7'his form is lo be completed and attached to the Summary Form of the Minnasota pollution Control Agency's(MPCA)Compliance <br /> Inspection�orm for F�cisting SuasurFace Sewage Traatment System9.Observations,interpretaiions,And conclusions must be <br /> completed by an inspsctor or designer.Cempleted form must be submitted to the Iocai unit of govomment within 15 days, <br /> Property owner neme(s): Q.O_�� <br /> Property address: �� •�01�1,►�.Q�• '¢Cj d,�pJq,��Q I�� <br /> Propelty owners eddress(if dl�Ferenq; , � <br /> County: ���i'�,t �.� Phone: �,S1. --U�,t�.� �4,��,��Y <br /> 1 hereby certlfy that!personaUy made the observatlons,.Inte►protabons. and cor�cluslons neported on this fam end thet thay er�e <br /> Colrect. <br /> Nam�: S'����,� Q,�„�r-�.�������� Certification number: ��„� <br /> Business Ilcenae name and number: 5-�t' '�G�'�'SZ�.bt.�, )1J C, � 3 q 1.}�„���^y�9�- 3 5 lo� or <br /> Name of locsl unft of govern ent' <br /> .._r. <br /> Signature: ��'� -•� �'�"�w �_ y Daie: � �' _ I .—Q�t <br /> (.T� - � <br /> �'r4-WW�StS�-31 Compliunca Inspection Fvrm for Existing SSTS <br /> //J�r�w <br />