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Property Owner(s) la�l}"� `x-''�`'� Fire No./ Parcel No.
<br /> _.._............._..._.�.1..�.�?_ A°`�1?-r��...�,:..-�_.._�.�� .��... .._ ....____......__........�........._...__..__._.._ _..._......___...._�...
<br /> Systein Componer�ts(P/ease descr/be the system�component�ar�d attach site sketr�i showing system/ocat/onJ:
<br /> �'�{ S`� 41 1 �`}.��1��`"se�'� t`.�'�� t t !4 t��:� ��rt� '1'r�'k l�( xN., � �D'?i') p��� �`j..�R/��1'�'' �!�1�E'a't.` ,� �
<br /> �k!-1�'�..� 1� "ta'��" �.�31�.12� '�� Wl a� 1�-t��'► b\ d� /a� r� f,�,Sr �'�'ca�1�.'��':.'v:. �5 'k�'��;a"4�"<'}5 l�S^M
<br /> What'meChod�were used to mak�the de�p�*+inatiens for the compllance Insuection?(Nof�:No standardp�otoco/exlsts
<br /> The fo/%w/ng/Ist Is not exhausth�,or/n sequent/a/orde�nor/ndicates wh/ch avmb/nadons may ne�cessary ln make a determinaUon)
<br /> Watertight tank(s) Hydraul[c Functionl�g Vertical Separation Distance �
<br /> ❑ Probed tank bottom. ❑ Searched for surface outlet v �Co�ducted soit borings ,�,�'.�,:��=>
<br /> ❑ Observed low Uquld leve{ ❑ •Perfo.tmed hydraullc test . DePtti to Iimitlng layer.�`�� "����
<br /> ! �'r1 a d��,�
<br /> ❑ Examined const. records �ti Searched for�seeping ln yard t�t J Depth to systerp bottom 1,� �
<br /> ar Examtned empty(pumped)tank ❑ Checked for baek up.in home ❑ �xamined records �' ''� �'�"`���.
<br /> ����
<br /> ❑ Probed outside tanlc for"black soll" � Excessive ponding tn soll system/D-ti�oxes ❑ CGU Limiting Layer Verification
<br /> o Pressuce/vacuum check O Homeowner testimony �, � 'o Other
<br /> ❑ Other ❑ Examined far surging In tank
<br /> �Ea�,.1KR=•,,:�:�> �?,� �;'�-��x:�<`�,,«}.c {�s t, � "Black soil":above soU syskem ta�
<br /> ❑ Other
<br /> Status.of the svstem �
<br /> Based on�he compliance criteria,the system status is: (check one) Cl failing:(to protect�groundwater) O an
<br /> imminent threat to piabiic h�alth or safety(ITPHS),'Cl nori=compliant�(moriitoring issue) �compliant�(none of the 3
<br /> previous conditions). Therefore,�tfiis.do�ument is a: ��Certificate of Compiiance ❑�Noti�e�of Noncompliance
<br /> zs this system an'E�RA Class`V Injectton.Well?� ❑ y�s � no __� _—
<br /> Certification. � . .. .� '
<br /> I.hereby certify as a state of Minnesota lit�nsed Inspector and/or Deslgner I or Qualitied Emptoyee Inspector anc(/or Qualifed Emptoyee
<br /> Desfgner I that I conducted an investfgatlon thaE accurately determined the compllance status of this system and thah my recorded
<br /> observations are accurate as of this date. ��Vo determfnation of future hydraullc performance has been nor can be made due to
<br /> unknown conditlons during system constructlon,abuse of the system,inadequate maintenance,or future water usage.
<br /> Inspector's name(print) `����� � -- �.��-ti'�-�'�"�S Phone �(a'� -- �"1� — '3��a�
<br /> License and/or Reglstratlon Numbet 3'�1� Address ��� �1��"�'C�L'C7 L-�• '1-a•'�-'
<br /> Employed by ����ti�� 1}.b G. ' Address � . f°�.�(.�'�... �'�17, .S.'��2�.
<br /> � �� � •�' i�-'; . Date rl�.a•�!',`C-�'')
<br /> Signature���"' U'� r ,�c -
<br /> UpUrade ReUuirements ,(derlved frnm M/nnesata Statutes§11S.55J
<br /> An IrnHS must be upgrad�+d,rep/ac�ed,or/Cs use d/scnnt/nucd w/th/n ten months of recelpt of thls no�ice or within a shorte�.period if
<br /> requlred by/oca/ordlnanc� If the syslem fa1/s ir�provlde s�clentg�nundwatei`pmtectlon,tften the system must be upyraded,
<br /> rep/aced, or ICs use discondnued wldh/n tfie t/me repufr�d b}�ru/e ot the loca/orr�lnanc� If an exlst/ng system Is not fa//Ing as defined in
<br /> /aw,.and has at/c�ast iwo feet of des'Ign so!/separat/on,then the syst`em ne+e�d natGe upgraded,repalred,rep/aced, o�/ts use
<br /> discont/nued,notw/thstanding any/oca/o�dinance Ifiatls more strlcl: Th/s does not app/y to systems In shor�/and a�eas, we//head
<br /> pro[�cfion areas,or t�iase use�d!n cnnne�cllon with 1`o�d,bevera9e,and/odg/ng establ/shments as defrned/n/aw, .
<br /> Suqgested AtfiachmenfiS . ��
<br /> 1) �'�Site sketch�could also include:�weil,i+veil setback to�y5tem,_dwelHng or other bulldings,.tank(s},reserved soil treatment area,
<br /> suifiace water�and soll'boring(ocatlons. Include as-built drawing if avafla6le.
<br /> 2) Soii borl�g logs,showing eacti hoMzbn.�'Irldlcate th'e'texture,color,reifozimorptilc features depth•to bedrock,standing water and
<br /> whether.the material is flll.
<br /> 3) A iist of any.and ali requlrements of the.local ordinance that.are di.ffer.ent from the state requirements referred to on this form.
<br /> 4) A homeowner survey of system performance,signed by the homeowner as being factual.
<br /> S) Monitoring data as appropriate.
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