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<br /> Property Owner(s) V yl�i ( '� J 'S� � Fire No./ Parcel IVo.
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<br /> Svstem Components (Please desaibe the/system coinpor�ents and attach site sketch sho ing syste��location).
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<br /> � n ' � �� ��1 _ ,,,q� � ,� ld /�
<br /> `�i%J�2/wJ� � ' /�-G.•�!'7'/� t� S `�F' �Cl I
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<br /> � ���.. �'v�u,��--L� - . � :
<br /> What metho s we used to make he d terminations for the m liance ins i n? (Note:No stand��d protocol exists.
<br /> �he rolloo-ving llst is not rxhaustive, or in sequenCial c�oer nor indicates which combinations may necessary to mak�a determrnation)
<br /> Watertight tank(s) Hydraulic Functioning Vertical Separation Distance
<br /> 6� Prob2d tank bottom ;� Search�d for surface outiet � Conducted soil borings ,
<br /> � Ubserved low liquid level ❑ Perforr�ed hydraulic test Depth to limiting layer__�___
<br /> � Examined const. records � Searci��d for seeping in yard Depth to systeri bottom
<br /> ;�( �camined empry(pumped) tank U �hecked for back-up in home (� Examined records
<br /> ❑ Probed outside t�nk for"biac!:soi�" U Excess v�pondinq in soi! system/D-boxes ❑ LGU Umiting La�'er Verification
<br /> O f�res�ure/vacuum checK �h( Homeowrer testimony ❑ Other �
<br /> ❑ 0[her_ � Examined fo�surying in tank
<br /> ❑ "Black soil"above soil system
<br /> ❑ OChe!'
<br /> Status of the svstem
<br /> Based on the compliance criteria, the system status is: (check one) ❑ failing (to protect groundwater) ❑ an
<br /> IfTi^IIIIC'(tt threat ta ,;ublic health or satety (I�TPE-iS), � non-compliant (monitoring issue) �compliant (:�one of the 3
<br /> urevi�us co iditions). Therefore, this document is a:� Certifcate of Comp!iance ❑ Nocice of Noncompliance
<br /> is this system an EPA Class V Injection Wel!? C) ves I�I ��c,
<br /> Certification
<br /> I hereby ceRity as a state or Minnesota licensed ?ns;�ctor and/or Designer i or Qualified Employee Inspector and/�r Qualified Employee
<br /> Desiyner? that I conducted an investigaticr thah accuracely deCermined the compiiance status of this system and that my recorded
<br /> observa:ions are accurate as of t��is date. No deterr7�ina�ion of future hydraulic perfiormance has been nor can be made due to
<br /> unknown conditions dur ng systern const:ruction, abuse of the system, inadequate main'tenance, or future water u�age.
<br /> Inspector's name(pnnt)_���i ��d�-f`�t�ib`N� Phone_���� �'�7� '-���7—.
<br /> Licer.se and/or Registration Number ___�� Address__ f —,.,r---�—�>
<br /> Ernpluyed 'Uy ; l��`� �N [` Address /i1 3� �C�u� �'3 ��.�t.o_�-�J�i�i �
<br /> 'c�. �1 r�,'r " — _"'_`� Date 4�_ ��— O�'
<br /> �iynuCU.�C __;L:� � r � r_/-�•d.eL_l..e�..-=' _,
<br /> UQ rade Requirements Ide����From P1innesota Stdtu[es�115.55)
<br /> An iTPNS m,ist be upg�ade� replacecJ, c;�its use discontinued wifhin ten months of�eceipt of thrs notice or within a shorter perrod rf
<br /> �e�uire0 bv 1oca1 n�dinance. If the system fails co provide suirlcient groundwater protection, then the system mu_Y be upgraded,
<br /> repia�ev, vr;ts use discontinued wichi�tne ti;��e requi�ed by ru/e o�the/oca/ordrnance. If an eristmg system is n,�t fai/ing as defined in
<br /> la:v, a��d has at leasr nvv�eet or desi_qn soil sepa�ation, then the system need not be upgraded,. �epaired, replacea. o�its use
<br /> uis�o;rc,�nuc�, nonvithstanding any locai ordrnance th,at is more strict. This dves not apply to svstems in shorelano areas, wel/head
<br /> protctzion areas; vr those used rr�cvnn�=c;on wich�ood, beveraye, and lodging establrshments as defrned rn law.
<br /> Suqqested Attachmenfis
<br /> 1) S�ce s�:etch cauld also include: vvell, �,vel�setback te system; dwelling or other buildinys, tank(s),reserved soil t�eatment area,
<br /> sur�ace water and soil boring locati�ns. Include as-built drawing iF availap)e.
<br /> ?) Soii boring logs, showiny each horizon. Indicate the iex�ure, color, reaoximorphic features depth to bedrack, standing water and
<br /> wne[hNr the macerial is fill.
<br /> 3) A li�,t of�ny and al! reyuirement�o`the locai orcinance that are different fror.� r;�e sWte r�quirements referred to on tnis form.
<br /> �) A hom�4vner sunrey of system perforrnance, siyned by the homeowner as being tactual.
<br /> 5,� Monitc�ing data as appropriate.
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