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98/19/2011 13:55 9528733112 PAGE 04/95 <br /> Parcel number: ___ _ System Status: Compliant ❑ NonCompliant <br /> (as determine y is iorm) <br /> Soil Separation Complia�ce and Clther Con�pliance <br /> Compl9ance Issue #3 f 4 � <br /> Date of obseNation: Reason for observation: ___� _.. <br /> This infvrmation on this fo does ot expire. ��� <br /> Compliance questionsJcriteria: (Required) Verification Mathod": (OpGonai) <br /> Check the a ►n riate box <br /> (Check the appropriate 6o:J <br /> For systems built prior tv Apri11, 1996, and not Conducted soil obsen►atlon(s)(attach boring logs) <br /> located in Shoreland or Wellhead Protection <br /> Area or not serving a food,beverage or ❑ wo previous verificatlons(attach boring Icgs) <br /> lodging establishment: ❑ Other:�-ap� ��� gJ��y� <br /> Does the system have at least a two-foot �,�^ � <br /> vertical separation distance from period(cally a �� <br /> saturated soil or bedrock? ❑Yes No <br /> For non-performance systems built Ap�l 1, T <br /> 1996,or later or for non-peiiormance systems "" i �"'� � <br /> located in Shoreland or Wellhead Protection 5oil observation does not expire. Previous observations <br /> Areas or serving a food,beverage or lodging by two independent parties are sufficient,unless site <br /> establishment: co�ditions have baen eltered, <br /> Does the syst@m have a three-foot vertical <br /> separation distance from periodlcally saturated <br /> soil or bedrock?' Yes No <br /> For reduced separation distance systems (i.e_, <br /> `performance"systems under old 7�SO.Oti?9 ar ' May be reduced by up to t 5 percent rf a0owed in local <br /> Type IV or V system under new 7080. 235o or ordinance. <br /> 7080.2400); •'No standard profoco/exisfs. This/ist;s nof exhaustive, <br /> Does the system meet the designed vertical in sequentia!oMer,nor does if iRdicate which <br /> separation distance from periodically saturated combirratlons are necessary to make ihis <br /> soil or bedrock?* � Yes No delerm/natlon. <br /> Any"no"answer indicates that fhe system!s/ailing to proteet <br /> ground water. <br /> Certification � � <br /> This forrn is to be completed and attached to the Summary Form of the Minnesata Pollution Control Agency's(MPCA}Compliance <br /> Inspection Form for Existing Subsurtace Sewage Treatment Systems.Obs�roadons,interpretations, and conclusians must be <br /> completed by an inspector or designer.Completed form must be submitted to the local unit of govemment within 15 days. <br /> Property owner name(s • ���_ � ___ __.__ __. <br /> Property address: �,� �_... -���� ----- .,.-•---- <br /> Property owner's addres5(if differenty: _, „�M---- --- -..... <br /> � <br /> County; ��,j/1,/�f ,..._ Phvne: —.._. .. ,_._._. <br /> I hereby certify that/personally made the observatrons, rnterpretatlon�,and conclusions reported on this form and that they are <br /> correct, . <br /> Name: �4� Sc n��lU'I� carti�icaqon number; �tv_5�_ ___ <br /> 8usiness license name an number; �]�,)j,�_�-V�(¢�` j��,a`rjQ� . _ _,_ or <br /> Name of local unit of ent; <br /> Signature: � Date: ! <br /> � �/- --- --.. <br /> wq•wwists4•J Comp(iance lnspection Form for ExistinQ SSTS <br />