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Property Owner(s) Fre No./ Parcel No. ..........................................................................._...............................-........................._............................................................................................................................ �s`Item Comic&" (Ple g6cribe rime SAeffltom Q -and attach site sketch showing system location): What methods were used to make the determinations for the compliance inspection?(Note.No standard protocol exists The following list is not exhaustive,or in sequential order nor indicates which combinations may necessary to make a determination) W �ght n s) Hydraulic Functioningrtical Separation Distance L; rT Rttom ❑ Searched for surface outlet ❑ Conducted soil borings .X ❑ Observed low liquid level �(❑ Performed hydraulic test Depth to limiting layer_� + ❑ Examined const.records ' t] Searched for seeping in yard X Depth to system bottom ❑ Examined empty(pumped)tank ❑ Checked for back-up in home ❑ Examined records ❑ Probed outside tank for"black soil" ❑ Excessive ponding in soil system/D-boxes ❑ LGU Limiting Layer Verification ❑ Pressu cuum check ,�,,�j Owner ony YN-5 C3 Other C3 Other/ "' �� ❑ Examined for surging in to k ❑ "Black soil"above soil system ❑ Other Status of the system Based on the compliance criteria,the system status is: (check one) ❑ failing (to protect groundwater) ❑ an imminent threat e-heai r safety(ITPHS), ❑ non-compliant(monitoring issue) [Aompliant(none of the 3 previous condins). Therefore, is document is a:A Certificate of Compliance ❑ Notice of Noncompliance Is this system an njection Well? ❑ yes Im no Certification I hereby certify as a state of Minnesota licensed Inspector and/or Designer I or Qualified Employee Inspector and/or Qualified Employee Designer I that I conducted an investigation that accurately determined the compliance status of this system and that my recorded observations are accurate as of this date. No determination of future hydraulic performance has been nor can be made due to unknown conditions during system construction,abuse of the system,inadequate maintenance,or future water usage. Inspector's name(print) /,1_A A. Phone 'Zf License and/ egistration Number '45:'/� Address Employed by 44 Zt Address Signature _ Date UDArade Reguirements [derived from Minnesota statutes,§115.55) An ITPHS must be upgraded,replaced,or/is use discontinued within ten months of receipt of this notice or within a shorter period/f required by local ordinance. If the system fails to prov/de sufc%nt groundwater proton, then the system must be upgraded, t'�replaced,or its use discontinued within the time required by rule or the local ordinance. If an existing system is not failing as defined in �aw, and has at least two feet of design loll separation, then the system need not be upgraded, repaired,replaced, or its use discontinued, notwithstanding any local ordinance that is more strict. This does not appty to systems in shoreland areas, wellhead protection areas, or those used in connection with food, beverage,and lodging estatrlishments as defined in law. Suggested Attachments 1) Site sketch could also include:well,well setback to system,dwelling or other buildings,tank(s),reserved soil treatment area, surface water and soil boring locations. Include as-built drawing if available. 2) Soil boring logs,showing each horizon. Indicate the texture,color, redoximorphic features depth to bedrock,standing water and whether the material is fill. 3) A list of any and all requirements of the local ordinance that are different from the state requirements referred to on this form. 4) A homeowner survey of system performance, signed by the homeowner as being factual. 5) Monitoring data as appropriate. Page 2 of 2