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10/08/2010 01:50 763497501.1 SPTESTINGINC PAGE 04/07 ' I Parcel number: System status: M Compliant ❑Noncompliant (as determined by flits firm) 30119e1310ration Compliance and/ Other Compliance- Compl'iance Inspection 0 for Existing SSTS Compliance Issue #3 of 4 Date of observation: � ��U.� �._��c7" 9� Reason for observation: � This information on this tbrm does not expire, — Compliance questions/criterla, (Required) Verification Method": (Optional) -Check the�pA►opriate box (Check the ePpropHafebox) For systems built ardor to April1, 1980,and not Conducted soil observation(s)(attach boring logs) located in Sltoreland or Wellhead Protection Area or not serving a food,beverage or ❑ Two previous verifications(attach boring logs) lodging establishment: r ❑ Other. _ .n _dr.LY,,rVl Does the system have at least a two-foot _ vertical separation d'rstanoe from periodically 'P4 i-yLfk � f saturated soil or bedrock? -❑Yes No - For non-performance systems built April 1, 1996,or later or for non-performance systems — located in Shoreland or Wellhead Protection Soil observation does not expire.Previous observations Areas or serving a food,beverage or lodging by two independent parties are sufficlent,unless site establishment: conditions have been altered. Does the system have a three-foot vertical separation distance Prom periodically saturated ._, oil or bedroch?• _ Yes No For reduced separation distance systems(i.e., "performance"systems under old 7080.0179 or * May be reduced by up to 15 pentent if Allowed in loofa/ Typo IV or V system under new 7060.2350 or ordinance, 7080.2400): •"No standard protocol exists. This list is not exhaustive, Does the system meet the designed vertical in sequential order,nor does it indicate which Reparation distance from periodically saturated combinations are necessary to malre this soil or bedrock?` _ E]Yes No dete►minaifon. Any"no"answer lndkdtes that the system is felling to protect ground water. Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MAGA)Compliance Inspection Form for Existing Subsurface Sewage Treatment Systems.Observatlons,interpretations,and conclusions must be completed by an inspector or designer.Completed fonts must be submitted to the local unit of government within 15 days, Property owner name(s): J. ,L Property address: —40- Property owner's address(if different): Count � +� Y- r!.5 1 Properly owner phone; (o l'L.•' -- I hereby certiry that 1 personally made the observations,inferpraetedons, and conclusions reported on this from And that they are correct Name: Certification number. Business license name and number., -Q•� -�'i �'� 1��,J 1�,-oil' �r l ^�� .t i aJ")•.3 s,�_ or Name of looal unit of government: _ Signature: Dale: www.pca.state.mn.us . 651.296-6300• 800.6573864 1TY 651.282.5332 ar 800-657-3864 • Available in altemaiive formats wq•wwlst's4.31 • 4124109 01w..w A-i 0