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Parcel number: System status: Compliant 0 Noncompliant (as determined by is form) • Soli Separation Compliance and Other Compliance Compliance Issue #3 f 4 Date of observation: 3 Reason for observation: This information on this form does no expire. Compliance questions/criteria: (Required) Verification Method": (Optional) (Check the appropriate pox) (Check the appropriate box) For systems built prior to April 1, 1996, and not soil observation(s)(attach boring logs) located in Shoreland or Wellhead Protection ?<Conducted Area or not serving a food, beverage or ❑ Two previous verifications (attach boring logs) lodging establishment: `� 0 Other: (– 1� Lo41E. Lerkyvt, Does the system have at least a two-foot 13',?P" 10V� I tl W}" 1, 10.1/4 vertical separation distance from periodically —� saturated soil or bedrock? Yes 0 No -j146G_ 1 t For non-performance systems built April 1, Al(MN& WiAL Ettlife.S4 DI%S4ildi 1996,or later or for non-performance systems located in Shoreland or Wellhead Protection Soll observation does not expire. Previous observations Areas or serving a food•beverage or lodging by two independent parties are sufficient, unless site establishment: conditions have been altered. Does the system have a three-foot vertical separation distance from periodically saturated soil or bedrock?' 0 Yes 0 No For reduced separation distance systems(i.e., "performance"systems under old 7080.0179 or ' May be reduced by up to 15 percent if allowed in local Type IV or V system under new 7080.2350 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 separation distance from periodically saturated combinations are necessary to make this soil or bedrock?' 0 Yes 0 No determination. Any"no"answer Indicates that the system Is falling to protect ground water. Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compliance Inspection Form for Existing Subsurface Sewage Treatment Systems.Observations, interpretations,and conclusions must be completed by an inspector or designer.1nCompletedrtform must be submitted to the local unit of government within 15 days. Property owner name(s): 1 Yom_ Le _ .._.... . -.. ...- - ....._...._.. Property address: ` O O d 1:4-14-S '• - Oono _ . Property owners address(if different): County: ._... Phone: .–�...----••---.. .. . . .. , .... ._ ..... I hereby certify that I personally made the observations, interpretations; and conclusions reported on this form and that they are correct. ll Name: ' Ca\ S4361 on Certification` number: 74 �'.5� _ • Business license name and number: _ c,04 ,:,a A ;� 1trrf`. 'a.SO" . -_ or Name of local u,/ gove en Signature: ' _. Date: #.:73// - – -- wq•wwists4-31 Compliance Inspection Form for Existing SSTS 4/1/08 50/t'0 39Vd ZTTEEL8Z56 Zt' Zt6Z/6Z/E0