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FROM i, RYS PHONE NO. : 4422091 Mar. 13 2005 08:43PM P2 <br /> Property Owner(s) Fire No./ Parcel No. <br /> S ste m o en (Please descri the system components and attach site sketch showing system locatron): <br /> / <br /> ��ads wereused tom a the determinations for the complianceinspection?(Note_No standard protocol exists: <br /> The fol%wing list&not exhaustire, or in sequential order nor indicates which combinations may necessary to make a daterminadon) <br /> Wtro <br /> ght tanks) Hyd ulic Functioning Ve I SeparationDistance <br /> ed tank bottom Sear for surface outlet Conducted soil borings <br /> O rved low liquid level ❑ P o d hydraulic test Z:edrecords <br /> limiting layer�i✓ <br /> Ermined const records rched for seeping in yard system bottom <br /> Exalt mined empty(pumped)tank Chec for back-up in home <br /> Pr Ibed outside tank for"black soil" ❑ essive ponding in soil system/D-boxes Cl LGLl Limiting Layer Verh1cation <br /> Pressu acuum check Homeowner testimony ❑ Other <br /> Other Avg'!��L� O Examined for surging in tank <br /> &'0-/7Ae_x ❑ "Black soil"above soil system <br /> C3 Other <br /> s of the stem <br /> B sed on the compliance criteria,the system status is: (check one) ❑ failing (top ect groundwater) ❑ an <br /> i minent threat to public health or safety(ITPHS), ❑ n mpliant(monitoring issue) compliant(none of the 3 <br /> p ious conditions). Therefore;this document is a: Ce"to of Compliance 103tike of Noncompliance <br /> I this system an EPA Class V Injection Well? es no <br /> C 'fi Lon <br /> I ereby certify as a state of Minnesota licensed Inspector and/or Designer I or Qualified Employee Inspector and/or Quailfled Employee <br /> D 'gner j that I conducted an investigation that accurately determined the compliance status of this system and that my recorded <br /> ot Servations are accurate as of this date. No determination of future hydraulic performance has been nor can be made due to <br /> ur known conditions during system construction, abuse of the system, inadequate maintenance,or future water usage. <br /> Inspector's name(print) JEFF SWEDLUND Phone -� <br /> License and/orRftistration Number 398 Address '5C <br /> Er ploYed by �[l v % , Address <br /> Signature <br /> 9 Date <br /> wade R ire is fder/ved from Minnesota Statutes§115.55) <br /> ITPHS must be upgraded, nepiaced,or its use discontinued within ten months of receipt of this notice or rWffi/n a shorter pvW if <br /> rewired by local oM/nance. If the system fails to provide sufflmnt groundwater proton, then the system must be upgraded, <br /> r�/a�ced, or les use d1scontlnued within the tame required by rule or the local ordinance. If an existing system is not faN/ng as de�ii�ed in <br /> lad,and has at least trvo feet of design sal separadon, then the system need not be upgraded, repaired,repbwd,or its use <br /> di condnued,notwfibstanding any local ord1nance that is more str/ct. This does not apply to systems in shore/and areas, wellhead <br /> prfinebon areas,or those used in connection with food,beverage,and lodging establlshmenh;as defined/n law. <br /> Suaaested Attachments <br /> 1) Site sketch could also include:well,well setback to system,dwelling or other buildings,tank(s),reserved soil treatment area, <br /> surface water and soil boring locations. Include as-built drawing if available. <br /> 2) Soil boring logs,showing each horizon. Indicate the texture,color,redoximorphic features depth to bedrock,standing water and <br /> whether the material is fill. <br /> 3) A list of any and all requirements of the local ordinance that are different 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. <br /> n.,..., <br />