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07/30/2009 21:14 7634975611 SPTESTINGINC PAGE 07l09
<br /> parcel number; � ._._. 5ystom st�tus: � � Compliank ❑ hioncompli�nl �
<br /> ....---� .. .__... _ _ ...............__.. ... _.. _._........
<br /> (as defe�'mined by Ihis form) .
<br /> Soil Separatinn Complian�e and Other Compliance— Compliance Inspection Form for Existing SSTS
<br /> Compliance Issue #3 of 4
<br /> Date of obsenrakion: 7�a,'��� „� Reason for observatfon_��¢�..�.�!�����
<br /> This in�ormalion an fhis fArm does no1 Bxp/re. '—
<br /> Compliance questions/critPria: (Required) Verification Method**• (ppllonal)
<br /> (CheGlc the appropria�e hox) ppropriale box)
<br /> •��--�--- �— (Check Ihe�
<br /> For systems built prior to Apr11 1, 1996,and nal I � ConcJucled soil observatlon(s)(attaoh borin lo s
<br /> {ocated In Shoreland or Wellhead Prolection 9 9 ) .
<br /> Area or not serving a food.heverage or � ❑ Two�revlous verifications(allach boring logs)
<br /> lodging establisl�ment: � �
<br /> ❑ Other: $.����50��., l. • ��4�,�
<br /> Does,lhe systsm heve et least a lwo-foot. �
<br /> vertical soparation tlistance from periodlcally � �,ra �� �� a� �9,A�p �,V�
<br /> saturatod sall or bedrock? Yes ❑ No �, '�, ,��5,�����+
<br /> For non-pefformance syslems built Aprii 1, '
<br /> 1996,or later or f�or non-performance sy�tems �""'"' -•� ' ---�--�-
<br /> Iocaled in Shoref2nd or Wellhead Protection Sail obsenration does nol ex�ire. Prevlous�bservaLlons
<br /> Areas or serving�a Food,beverAge or lodging by�o independent parlles aro sufficlent, unless slle
<br /> establishment: canditions have been all'ered.
<br /> DoQs the sy5tem have a three-foot vertical �
<br /> saparetion diskance from periodlcally saturated
<br /> soll or bedrocic?' . Yes ,No , .
<br /> , • .
<br /> For reduced separallon distance systems�(i.�.,
<br /> "performancs'systems under old 7080,0179 or ' May b�reduced by up to 15 percenl if allowed in local
<br /> Type IV or V syslem under new 7080.2350 or or'dinance. �
<br />, �080.2400): ' •'No standa►'d pro�ocol exlsts. Thts lisf is not exhsustive,
<br /> Does the syskem meet the designecl veHical , in sequvntlal order, ner does it lndicate whlch
<br /> separation distance From periodicatly saturated cvmbinarlons are necessary to make thi.s
<br /> soll or bedrock?M .. Yes No deferminaRion.
<br /> Any"no"answer indlc�ies that the system/s�fallin�►to protecf
<br /> ground water. �
<br /> Certification
<br /> This form Is to bd compleLed and attached to tlie Summary Form of the Mlnnesota Pollution Co�tro)Agency's(MPCA)Compllance
<br /> Inspectlon Form for Exlsting SubsUrface Sewage Treatment Systems. Obsorvatiorts, interpretations,and concluslons must be
<br /> aom�leied by an.inRpector or designe�.Completed form must be submllted to the locsl unit vf goverrament within 15 c1ay�.
<br /> Pro�aerty owner name(s): y1�AJ+� 141 f,�.NI f�'!J� ,�w , ,,`_
<br /> Property address: ,�„�Q 0 1L'�.11�V1,.. M lAr1.1�?������� W .. .,.._
<br /> Property owner's address(It.dliferen�): � . �
<br /> �. �.._
<br /> County: _,�fiG � •. y l.� ,� Property owner phone: ��,p��, ..a�a ^3 S Z �
<br /> I hereby certify tha�1 par.sonally made th��observallons, interpretarions, �nd conclua/ons r�sported on thls fnrni and tha(th�y ere
<br /> carect
<br /> Name:. ,j�`��,��(,�y.���i�,ti�� _ Certffication�umber. r� a�
<br /> Buslness license name ancl number. ���{�,fr�la„���„ L� �� 7_
<br /> ��,.�,�.,�� 3*S c�� _ o�
<br /> Name of Iccal ni!af gov�mmerit: � ' ,
<br /> Signatur�: � �� ^. �� . � �
<br /> _ Date- -� ��_
<br /> www.pca.state.mn.us � • 651•�96=6]00 • 800•657-3864 • TTY 691-282-533Y or 800�657•386�1 • Available In altemative formats
<br /> wn-wwic�sd-it . A/1A/IM L.
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