|
03122/2011 22:49 7634975011 SPTESTINGINC PAGE 07/09
<br /> . , II
<br /> �
<br /> Parcel r�i,imk�er: System status: �Compliank [� Noncompliant ,
<br /> ._.......__.—. .....•-- ----._._...,..,._..._....._�
<br /> (as determil�ed by fhis famt) '
<br /> �oiM S�a���rak�on CwrtnpMoance �r�d O�heK �Compliance- Compliance ►nspectian Form�or Existing SST3
<br /> Complia�nce Issue #3 of 4 �
<br /> �ato of obseroatlon: _3=1.,y.�.�.P 1�......_,....,. Reason ior abseNation_�Q���1y���-----.--.._...,,.-,-- '
<br /> 7his informaflon on fhls fonn c�oc�s noi�expire. I
<br /> Gompliance q��estpa�t�/criterla: (Re��dred) Veriilcation Method'"'. (Optinnal)
<br /> _ Cl�eck the„approprtele box) ._,.� _...�...,.:..._______— (Checfc tho approprlai�e box)
<br /> Fo�systems built prlor lo April 1, 199f9, and not �> Coriducted soil observstion(s) (attach boring logs)
<br /> Ic�cated in Sho�oland or Wellheed Prote�tion
<br /> Area or not s��ing a food,beverage or ❑ Two previous verPf�ic�tivn:(attach boring logs)
<br /> IodgingestabHshment: r] Other; '3•3_,'.;__������s���?�r?_Y.s.•I
<br /> Does ihe system have at least a two-foot �
<br /> v2rllcAl separatlon distance fmm periodically ��"�;""� ' ��, , �
<br /> saturated s�il o�.bedrock? _� _ �Ycs _CI No . � ��0.1L!a����c�_,�3�..,�,c���a.�
<br /> For non-performance systpms built April �i, ..___ _._._._...._ '
<br /> 1986,or later or for non-perfarmance systems Sofl obseruetion doc�s not expl�e. Prevlous observations
<br /> luc�kod in Shoreland or WeIlhFad Protectlon by two inaependont parties are sufFcfent, unleas site
<br /> Areas or serving a food, bpver�ge or lodgfng condition�have been altered. '
<br /> eStAbllshment: �
<br /> aoes Ihe system have a three-foot vertical
<br /> sepa�ation distance from periodically�aturated �
<br /> soil or bedrocic? .,.___,_._ _,,,_ O Yes ❑No,_„ i
<br /> For reduced separation clist�nce syst�ms(i.e., x May be;rsduced by up b 15 per�cent If allowed!n locaf
<br /> "��erformanr,e" systems under old 708U.0179 or orid�nence. a.tn' I
<br /> Typo IV or V system under new 7080_2350 or
<br /> 708�2400): "'No statid�rd prntocol exfsl`s. Tlils list is nol exheustive,
<br /> Goes the system meet the deslgned vertical in sequ�nhal orrfer, nor does it indlc�to which �
<br /> separation distance from�erlodf�ally saturated combfneUons e►E nec�essary fo malse this
<br /> soil or bedrocic?' Yes ❑ No dcrianninetion.
<br /> ,
<br /> .._:........ .......-�-- —�-�-•---- .._ _..
<br /> Arny"�►o"�nswer/ndFcates that the sp✓s(pm Is Faflfng to p�rot�ect ',
<br /> ,�nv�md Nvate� �
<br /> Ce�rtific�ax�on
<br /> T'his form Is to be completed and attached to the Summary Form of the Minnosota P`ollu6on Conl�ol Agency's(MPC/�)Compllance
<br /> Inspect��ot�Formi fv��xi�t�nq Sub9t�rface Sewage Treatment Systems,Obseroatuons,interprelalfons, �nd conalu�ions must be
<br /> completed by an inspector or deslgner. Completed form must be sukfmilted to the local unit oi governm�ant within 1 b days.
<br /> Froperty owne�neme(s): �lD�'�p�'�l�t 1� ��'�'L—�--...,.----. .--_ ----�
<br /> I�rope�ty�ddr�ess: _���_���L�?_1-�..._.�.�¢��.tJ:�r��c2.u�,:...:- _,�._,_,....---•�--
<br /> Property owner's address(if dlfferent); ,.,,.......--- --..,.:...._._ _._,�_.._ -----.....__....
<br /> Counly: .._��4 '�1�., ,__ �,,,�,,, Property owner phon�: _°I�!1,��5� — 9 o'�t7? '
<br /> 1 her�by certlfy llta(I personally made tf�e obse►vations, interprefat/ons, and conclusions rnported on fhfs fonn and that th�ey a►e
<br /> correct.
<br /> �lame; �.�'j'��/��.1 ��?�. S G W4,1���'"A� ..._ Certilication number �v��1.��,..,._�__�.,.�..,.
<br /> Rusine�s license name arad number S�•ri' - 'r��•��v.'�j a,�1.;�_1iJ�.C� I.1S�,kk 'i�' 4 'F' �.::Z4v3�``LL)—:S�il.�Ga.._ ar
<br /> :" �_I 1�,:,.
<br /> Alamo of 1oc21 unit af govemment� ---......._,........_.. . .
<br /> _. ..--_ --- . . ,,
<br /> Signaturc: Date:
<br /> ��_..�..,._,,,_.,...,,._.....___. _.__...:...,:.:....�......... —
<br /> www.pca.sLahe.mn.us • 651-296-6300 • Q00-657-3864 • TTY 651-282-5331 or 800-657-38G4 • Availahle in altern�Nve io�m�ts
<br />
|