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May 171011:00a 763-213-0695 p.4 <br /> Parcel number: "7SZ t jzi 67,,,cs,..42 System status: SCompliant 0 Noncompliant <br /> (as determined by this form) <br /> Soil Separation Compliance and Other Compliance <br /> Compliance Issue #3 of 4 r <br /> Dale of observation: 6--I3-10 Reason for observation: Ska.4/3 <br /> This information on this form does not expire. <br /> Compliance questionslcriteria: (Required) Verification Method*': (Optional) <br /> (Check the appropriate box) (Check the appropriate box) <br /> Far systems built prior to April 1, 1996, and not [I Conducted soil observation(s)(attach boring logs) <br /> located in Shoreland or Wellhead Protection <br /> Area or not serving a food, beverage or 0 Two previous verifications(attach boring logs) <br /> lodging establishment: 0 Other. <br /> Does the system have at least a two-foot <br /> vertical separation distance from periodically <br /> saturated soil or bedrock? 0 Yes ❑ No <br /> For non-performance systems built April 1, <br /> 1996,or later or for non-performance systems Soil observation does not expire.Previous observations <br /> located in Shoreland or Wellhead Protection by two independent parties are sufficient, unless site <br /> Areas or serving a food,beverage or lodging conditions have been altered. <br /> establishment: <br /> Does the system have a three-foot vertical <br /> separation distance from periodically saturated <br /> soil or bedrock?' EX Yes ❑ No <br /> For reduced separation distance systems(i.e., <br /> 'performance" systems under old 7080.0179 or May <br /> • Maybe ordinance.reduced by up to 15 percent if allowed in local <br /> be <br /> Type IV or V system under new 7080. 2350 or <br /> 7080.2400): "No standard protocol exists. This list is not exhaustive, <br /> Does the system meet the designed vertical in sequential order,nor does it indicate which <br /> separation distance from periodically saturated combinations are necessary to make this <br /> soil or bedrock?' NT Yes 0 No determination. <br /> Any"no"answer indicates that the system is failing to protect <br /> ground water. <br /> Certification <br /> This form is to be competed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compliance <br /> Inspection Form for Existing Subsurface Sewage Treatment Systems.Observations, interpretations,and conclusions must be <br /> completed by an inspector or designer. Completed form must be submitted to the local unit of government within 15 days. <br /> Property owner name(s): 1<.. <br /> Property address: 17'57) CP fiono--- (0 i''4 X+4tv.(2_ !"e`'� <br /> Property owner's address (if different): <br /> County: .knvr� - _ Phone: �� '�F - 17(3 7 <br /> I hereby certify that I personally made the observations, interpretations, and conclusions reported on this form and that they are <br /> correct. <br /> Name: Certification number. 6 3S-- <br /> Business license rfdme and number: fi-� 12 , " 73 — or <br /> Name of local unit of government: <br /> Signature: Date: 6-- l33 — <br /> wq•wwists4.31 Compliance Inspection Form for Existing SSTS <br />