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94/27/2619 21:26 7634975011 � SPTESTINGINC PAGE 06/09
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<br /> Parcel number: ..:.._ . _ _,.. _ ._._._..,...._.. ___ . : ` _ System Stak�is; ' Q�Com�li�nt ❑NoncOmpliant •
<br /> • (as d�larmined hy�l�ls formJ .
<br /> Soil Separation Compliance and Other Gompliance- Compliance lnspection Form for Existing SS1'jS
<br /> Compliance Issue #3 of 4 � �
<br /> D�le of qUsgrv�tion: � � . �r_4'5�.�.�'� ��,��„'�_ �
<br /> ,�,�J�jt�CI,�O._,v Reason fnr observatlon:
<br /> This inforrnallon on►hls form d�es no(explre. • �
<br /> Compfiance questionslo�iteria: (Required) Verificativn Method*�: (Oplional) '
<br /> __(Ch9C1(fl1g 8q�pf1A1@ bOX) , ' (Check!he eppropriate boxJ '
<br /> Far systems bulll prlar lo April 1, 1998,and nal I � Conducted soil obs�rvation(s)(attach boring logs}
<br /> locatsd fn Sl�orelend or Wellhead Protection �,�,�� �
<br /> Are�or nol serving a Food,beverac�e or � � � (] Two�arovious verifications(attach boring logs) .
<br /> lodging astahllshmenL- I � Q Othor. 3�,y'��1 .�� y�s�g���
<br /> Doe&.lhe system have al loast a iwo-foot ' ,
<br /> vertical senaralion distance from periqdic�lly J�
<br /> saturated soil or bedrocl<? _�,Yes No _, '
<br /> For nvrn•perForm�nca syslems built April 1, , � T ��
<br /> 1996,ar laler or For non-��rform�nce syst�ms � ' -���•=
<br /> located in Shor�land or wellhesd Protectlon Soll obsarvallon does nol expire. Previous p�sarvaUons .
<br /> Areas or serving�a food,heverage or lodging by iwo indepenclent parlles are sufficienk, unless slte �
<br /> esLablishmenl; ��ndltlons have been All'ered. �
<br /> Doos khe syslem have a three-Foot verticai ' ;
<br /> separaki�n dlstance from �eriodlcally saturetetl ' � �
<br /> soil or bedrock?' _ �, ' Q Yes ❑ Np ' i
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<br /> ' �or reduced separakian dlstence systems'(i.e., �
<br /> "performance"systems under old 7080.0179�r �' May ba reduced by up to 95 perG�nt if allowed In local ;
<br /> Type IV or V system unde�new 7080.2350 or ordrnance.
<br /> . 7080,7,q00): ' � "'No standard profocol exl.sts. This Ust Is nvt exhausffve,
<br /> Daes the system meel the designed vertical in sequential order, na does 1(indicafe whlch� •
<br /> soraratian disk�nce from periodically saturated combinations are necessary io make fflfs
<br /> soil or bedrock?" �Yes ❑ No delermin�tivn,
<br /> Any"no"answer indicates fhat[he system fs fafling to protect• '
<br /> �►round w,�ter. '
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<br /> Certification
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<br /> This Farm is to be cnmpl�ked and alteched to lhe Summary Form of the Miranesala Pollution Control Agency's(MPCA)Compliance .
<br /> Inspection Form for Existing Su�surtae�Seuva�e Treakment Systams. Observations,interpretations,and conduslons must be .
<br /> completod by An�Inspector or deslgner.��orripleted iorm musl be submitted to lhe lacal unll of goven�ment within 15 days. ;
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<br /> P�operty owner name(s): ���j�1� � � �
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<br /> �S �fl�� * ��
<br /> Properry�cldress: �� \����_G��,',L� p'��ys,0
<br /> �t--- 4. „_.
<br /> Property owner's address(if.dltferenq: �w � ,
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<br /> Cc,unty: ,�.�!.,�.�.��p��,� Properly owner phone: 1^I.1,y�..Q�,.�:�.�_.• ?,eay��
<br /> 1 hareby cerl/fy fhal 1 personally made fhe observaflans, lncerpratafions, And condusions repor(ed an thls form and that they ere
<br /> corrEct. � .
<br /> Neme: ,����/¢�� �,,•5�1�.1�!V�� _ Cert►f�ctation number. f� a.� I
<br /> Business license nerne and number. ��,Q��i�lU.1]�„ �•1,AL. L �` � ' ,
<br /> 1.:C,_3��_l��.3=....4°1.�- ?,5 4�j,o � or
<br /> Name of local nit oF govemment:
<br /> Signat��re: '/'�'� � —�-..`. ,r -
<br /> Dato: �'-�?,J1-�OLO
<br /> www.pca.state.mn.us ' • 651•39fr•6-]OQ • A00•657-386q � TTY 651•2BZ•5337.nr.Rflfl�h57•iRlv4 . AvallahlA in a�rom���„a�.,.,,,.,�� •
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