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10/24/2008 92:35 7634975011 SPTESTINGINC PAGE 65109 <br /> Parcel numbe� System status: � Compliant ❑NancompileM <br /> (as deten»Ined by thfs form) <br /> Soil Separa�tion Cornpliance and Other Compl ance <br /> Complia�ce Issue #3 of 4 <br /> Date of observatfon: � —�e� Reason for observa on: , <br /> 'This info►metion on this fo►m does nat exp!►e. � <br />� � Compliance questlon9lariteria: (Requirec� ' Ve�iflc�kion Method"'": (Optio�al� <br /> Check the a ro rtate box (Check the app►opriat�6ox) <br /> For systems built prior to Aprll 1,1996,and not � Conducled soil obsenration(s)(atiach boring logs) <br /> located in Shoreland or Wellhead Protection <br /> Area or not serving a food,beverage or �,�,Kg ❑ 7wo previous ve�iflcatlons(attach boring logs) <br /> lodging establlshmen� 3',�� ❑ Other: M� s�,.-�v�bvori,�s�� <br /> Does the system have at least a lwo-foot �, � �b �,Y,'_ ,�,� a�p� R L,a� <br /> vertical seperdiion distance from perivdically <br /> satursted soil or bedrock? �Yes ❑No , ��jo� 3.�4� � 3 ��� <br /> For non-performance syst,ems built Apnt 1, . <br /> 1996�or late�ar for non-performence syst�ms Soll observation doas not�xpire. Previous vbservatlons <br /> Iocated U Shareland o�Wellhead Protection by�wo Independent pafies are suffident,unless site <br /> Aress or serving a food,beverege or lodging condiaons have been eltered, <br /> establishment: <br /> Does the system have a tfuee-foot vertical <br /> separation distance from penodically saturdted � <br /> soil o�bedrock?* _ , Yes No <br /> For roduced separallon distance systems(i.e., <br /> "perFormance"systems under old 7080.a179 or I " May be reduced by up to 15 perceni if allowed In IocA! <br /> Type IV or V system under new 7080.2350 0� . onl(nence. <br /> 7060.7A00): I "No standard protocol exists. Th►s list is not exheusNve, <br /> Does lhe system meet the designed vertical in sequenti�gl order,nor does it indic�fa which <br /> separAtlon distance frorn periodlcally saturated combinatiww�►e necessary io mahe thi.s • <br /> soil or bedrock7" Yes []No det�►minetion. <br /> Any"no"answe►'iedicai�es that the system IF f�fling to prote�t ' " ' <br /> ground water. � <br /> Certification �� <br /> This fortn Is to be completed And attached to lhe Summary Form of t e Minnesota Pollution Control Agency's(MPCA)Compliance <br /> InRpe�on Form for�xlsting SubsurFace sewage Treelxnent Sy ms.Observstlons,Interpratations,and c�nGusloas must be <br /> completed by An Inspector or designer.Complet�d form must bv sub itled to 1he local untt vf govemment within 15 days. <br /> Properly ovmer name(s): ��p�o+� A�P� <br /> properly address: �,�.Jp a��'�..�b'�� '� J .,....- __.__._.._-- <br /> Property owner's address(iF dl��nt): � ` <br /> County: �1�.1�.1�i�4�!� „ Phone: '�,�4�to�Doy� _ <br /> 1 he►sby certlfy that 1 personelly made the observallons, inte�protaB s, and oonalusicns napart�d on this fvrm and fhaf they a►� <br /> ubrrect. � . <br /> , <br /> 1 <br /> Name• �'����� �. _�L w^:%_�� G��fication number. �p e�,� „_, <br /> Businoss license nelme end number. S�'�C' �'��"��i 1�.L�1� .�' 3�° 4 _ _ or <br /> Name of loc�l unit of gove menk: ' <br /> Slgnalure: � �--�—..-- _ Dete: ,�,�— •(� <br /> rvt�-wwists4•31 I ' " tompliance Inspection Forrn fo►'Existing SSTS <br /> wi�ino . <br />