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<br /> 1
<br /> What methods were used to make the detem�inations f the compliance inspectio ? �
<br /> �
<br /> Please attach the foRowia¢:
<br /> 1) Site sketc6. Suggested items for diawing include:Well,well setback to system,dvvelling or othc establishment,tank(s),soii ueatrnent system,
<br /> reserved soil tc�unent area,curtain drain,property lines,watervvays,and buried lines(t�ose NOT installed by the utility). include sizes and
<br /> length a�approximate distances 5vm fi�ced reference points'such as s�eets and buildings.
<br /> 2) Soil b�ing logs,showing each horizoa Indicate the texture,structure>color,depth of each diffe�ent soit type,evidence of mottling,bedrock
<br /> and standing water and whether the materiat is fiU. Locate each boring a�attached site sketch.
<br /> 3) A list of any and ail reqt�+*e*±+P�ts ofthe local ordinance that are different than the�te requirtments refeired to on this form.
<br /> CERTIFICATION
<br /> A. I hereby catify that all the infomiation I ha vi regazding the individual sewage h�eat�nt system is true,accurate,and complete.
<br /> Property Owner GL��"0�7�� ���� Date -�7J
<br /> B. I hereby certify as a state of Minnesota Gcensed Inspector andlor Designer I or Qualified Employee Inspector and/or Qualified E loyce
<br /> Designer I that I conducted an investigation in accordance wit6 applicable requiiema►ts that accurately deteimined the compliance status of this
<br /> system and that my observations recorded are accutate as of this date. No dete�mination of future hydraulic performance has been nor can be
<br /> made due to anki►ovm conditions during systcm constructio�;�abuse of the system,inadequate maintenance,or future water usage.
<br /> Inspector's name(print)�i�M C.,��. �r� � Phone
<br /> License and/or Re gisaation Numbcr Address � � ����'f�Q-�
<br /> Employed by - Address' �
<br /> Valid until��,unless the system b�omes an imminent th�eat to public health or safety as defined at Minn.R.7080.0020,subp.19a,before
<br /> that ricrbe. �
<br /> Signature Date L� -' a+�� ~ l'�
<br /> UP91'dd@ i'I�t'la
<br /> Minnesota Statutes§115.55("law")Upgrade Requirements
<br /> Any situatiorr with the pofenffal to immediately and adversely affect or th�eaten puWic heal�or safety,must be upgraded,replaced,or
<br /> fts use discontinued within fen�nths of receipt of this notice or within a sho�ter period of time if r�equi�ed by iocal oMinance.
<br /> It the/ocal unit of govemment with jurisdicfion over the system has adopted an adinance containing altemative local standards,ths
<br /> existing system must compiy with the ordinance. lf the system does not compty with the ordinance,it must be upgraded,repfaced,or
<br /> its use discontinued acao�ding to the ordinance.
<br /> !f a seepage pit,drywed,cesspool,or leaching pit exists and the bcal unit of govemment witli jurisdiction over the system has not
<br /> adopted loca!standaids to the contrary,the system is failing and must be upgraded,replaced,or its use disco�inued witi►in the time
<br /> required by local ordinance.
<br /> Jf the system fails to provide sufllcient groundwater protection,then the local unit of govemment or its agent shall order that the system
<br /> be upgraded,replaced,or its use disconSnued wffhin the time requfred by n�le or the loca!adinance.
<br /> lf an existing system is nof failing as defined in/aw,and has at/east Mro feet of design sal separation,then the system need not be
<br /> upgraded,repaired,replaced,or its use discontinued,noiwithstandir►g any Aoca!adinance that is moie strid. This does not apply to
<br /> systems in shoreland a�as, wellhead protection areas,or thase used ip cavrnectlon wlth food,beverage,and lodging estaWfshments
<br /> as defined in law.
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