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i <br /> , . ,, <br /> , <br /> Parcel number. <br /> . System status: ❑Compliant [$Noncompliant <br /> (as detennined by thls form) . <br /> � <br /> Soil Separation Compliance and Other Comp iance <br /> Compliance Issue #3 of 4 <br /> Dateofobsenration: � -1) �(��, Reasonfirob�rv8 on: ``y''�F''�'�h�1� <br /> This infnmration on this foim does not expire. � <br /> � Compliance quest�ons/criteria. (Required) � Verification Method**- <br /> Check the a ro riate box . (Optional) <br /> � (Check the appropriate box) <br /> For systems built prior to April 1, 1896,and not ! <br /> located in Shoreland or Weilhead Protection i � Conducted soil observation(s)(attach boring logs) <br /> Area or not serving a food,beverage or ❑ Two previ�ou�s v� ti s(atta�i bo�ing�oys) <br /> lodging establishment: 3,� 9 <br /> Does the system have at least a two-foot ❑ �ther. _yb�-(L�a s��1 �y'E�.y�f <br /> vertical separation distance from periodically I �t�Y✓t �C��L��-�S 3l�`���y2,'� <br /> saturated soi!or bedrock? Yes No �� 5,��,�Q� „�� �,( ��. <br /> For non-pertoRnance systems built April 1, <br /> 1996,or later or for non-perFoRnance systems <br /> located in Shoreland or Wellhead Protection Soif observation does not expire.Previous obsenrations <br /> Areas or serving a food.beverage or lodging by two independent partles are suffiaent,unless site <br /> establishment: conditions have been altered. <br /> Does the system have a three-foot vertical <br /> separation distance from periodically saturated <br /> soil or bedrock?" � Yes No <br /> For reduced separation distance systems(i.e., � <br /> "pertormance"systems under old 7080.0179 or � ` May be Bduced by up to 15 pencent if allowed in loce/ <br /> Type iV ar V system under new 70$(�.�350 or � orrlinance. <br /> 7080.2400): � '"*No standard protoco/exlsts. This lisf Is not exhaustive, <br /> Does the system meet the designed vertical In sequenbal onier,nor does it Indicate which <br /> separation distance from pe�iadically saturated � combinations are necessary to make thls � <br /> soil or bedrock?' Yes No j determfnation. <br /> Any"no"answer indicates that the system is failing to protect � • <br /> ground water. � <br /> � <br /> � <br /> Certification i <br /> This form is to be completed and attached to the Summary FoRn of tlhe Minnesota Pollution Control Agency's(MPCA)Cntttpli�nce <br /> inspecdon Form for Existing SubsurFace Sewage Treatment Sy tems.Observations,interpretations,and conGusions must be <br /> completed by an inspecto�or designer.Completed form must be su mitted to the local unit of govemment within 15 days. <br /> Property owner name(s): �/ �+�L._ p p � <br /> Property address: 1�,� �.�-0�,,.L,����,�,,. �,�j I d.��Q <br /> Property owner's address(if ditferent): <br /> County� _��'�ws'�.�Q�'�-'�'1� Phone: �t c'� �1-},�-al`'� --- l�`'�'.C-s <br /> I hereby certify that I personally made the obseiva6ons,.interpretatio I s, and caondusions reported on this form and fhaf ihey are <br /> correct <br /> Name: 5"S G Certification number: (o a� <br /> Business license name and number. 5-'�' �i����,` � � 3 oy t,�, �(�� 4 q 7 �� „l or <br /> Name of local unit of govem ent• � <br /> Signature: �.,. � �----_�_____ Date: �J �a, (-- <br /> wq-wwists4-31 CompliQnce(nspection form for Existing SSTS <br /> 4/i/08 � <br />