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12/16/20�8 22:4� 7634975011 SPTESTINGINC I PAGE 07/13
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<br /> Parcel number. _ 9ystem atetus: �Com liant
<br /> ^ �� (as dei�rmined by this IPorm) p Nonc mpllant
<br /> �
<br /> Soil :�epara#ioet �Compllance and O�her Compliance
<br /> Compliance Issue'� #3 of q
<br /> Date of obsen��tian: �.�5�{��,/ Reason fo�obsery8tion: ����
<br /> Thls infi�rmafion on this�orm doea nof expire.~ � `-
<br />� � Compilance questio fis/c�iterla: (Require� Verlficatlan Method**: (pptlonal)
<br /> _�(Checic the approprrat�g box) �
<br /> •-- (Check the apprvpnab hox)
<br /> For syst�ms built prior tol qprU 1, �998,and not
<br /> locatetl in Shoreland or�ellhead Protectlon � Conducted soil obsetvadon(s)(at ah boring logs)
<br /> Aree or not aerving�foo ,beversge or [l l"wo prevlous verlticabons(eltech ring logs)
<br /> lodging establishmenl: !
<br /> Does the system have ail least a iwo-foot � Othe� _
<br /> vecticai separation distan�e from periadically
<br /> _5�tu�stea so�i o�aearo� � Yes ❑ No � '�~`
<br /> For non-perFormance sy ema buflt Aprii 1, ���
<br /> 1996,or later or for non- erformance systems �
<br /> located in Shvreland or ellhead Protection Soll observation does not expire. Previou observations
<br /> Areas or serving a food,beverage or lodging bY��independent parHes are sufficie�t, unlasa site
<br /> establlshment: , conditlons have been altered.
<br /> Doea ihe system have a t�ree-faot verHcal
<br /> separaiion distance from�erfodically saturated �
<br /> soil_,,, or bedrock?" , Yes No
<br /> For reduced aeparation di�tanae systems(i.e., I
<br /> "performance°systems ur�der old 7080.0179 0� ' May be r�duced by up to 75 per�ent if 111owed In local
<br /> Typ�IV o�V system under new 70a0.2350 or � � andinance.
<br /> 7080.2400): *•No standard profocol exista. This list is ot�acMaus6ve,
<br /> Does the system meet the�designed vartica) in sequentia/o►d�r,nor does it ind�cete h�h
<br /> separation distance fram�erlodically satureted combinations are neceasary b ma/ce th
<br /> soil or bed`rook?•,_�_ Yas No defsrminatlon.
<br /> Any"no"answ�r fndicate�fhat the sysfem is falling tv profi�ct
<br /> ground wAter. I II
<br /> C@�1�C8�1011 ,
<br /> Thls farm is to be complet�d a�d atiached to the Summary Fortr�of tho Minnesota Pollution Control Agency's(MPC Compliance
<br /> Inspectio� �orm for Exls#ing Subsurface Sewage Trestme�t Systems,Observations,Interpretations,end co�du Ions must b�
<br /> completed by�n inspector br designer.Completed ferm must be submkted to the local unil of govemment within 15 ays.
<br /> Property owner n�me(s): ���, d�. ��,;a� 1a�Ch�y _,,,Q�.�y+�-
<br /> Property address: �1�.;5' �,q..���pr��.{,p,�,,�,.�1 �=d�A,� , r�d�.l,� '
<br /> Property owner's address(�F dlFferent): _
<br /> _ ,�---��--,—
<br /> Count / � �'—
<br /> y� —,I�' '!�1� 1 „ Phone: ��Z,��40��^ .C� 2 r!
<br /> �T
<br /> !hereby certiry that l perso�elly made#he observedons,interpnetsfions, end conclusions reported on�la form�nd th t they a�
<br /> correct_
<br /> Name: � ° � i ��(��� �:rt�� Certification number. (pa�
<br /> aus�ness��cense name end Inumbec 5-5,,._'_�-5��,1fJ. 'L. 1..1 L�,�' .3 or `
<br /> Name of local unit of govem�rnent: '
<br /> Signalure: ��_�� _,�-._._.... � . Date: 1 a-lc.� -04,� . ..—
<br /> wq-wwistsq-3 f � CompliQnce Inspection Form jor xisting SSTS
<br /> 4/1/08 �
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