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Property.Owner(s)_ 0.4=. Fire No./ Parcel No <br /> System Components(P/ease describe the system components and attach <br /> site sketch showing system/ocation): <br /> Whi t'methods were used to snake the determinations for the ronin iance Inspection <br /> The following Ast Is not exhaustive,or In sequential order nor Indicates which combinations may necNestsary to makera determin/aG"o <br /> Watertight tank(s) Hydraulic Functioning vertical Separation Distance <br /> ❑ Probed tank bottom. ❑ Searched for surface outlet Lot • Conducted soil borings <br /> ❑ Observed low liquid level ❑ Performed hydraulic test <br /> Depth to limiting layer. <br /> ❑ Examined const. records 0 Searched for seeping in yard VA'O <br /> El em Depth to system bottom .D '-t <br /> pty(pumped)tank ❑ Checked for back-up In home ❑ Examined records <br /> ❑ Probed outside tank for"black Boll" a Excessive pondiin soli system/D-�1Q <br /> ng boxes ❑ LGU Limiting Layer Verification <br /> ❑ Pressure/vacuum check ❑ Homeowner testimony .. <br /> C1 Other <br /> ❑ Other <br /> ❑ Examined for surging In tank <br /> "Black soil"above soil system�AO <br /> {�►�'bs.��-4�awl`P�$ �n�..�..�� 5ai1.T, ❑ Other <br /> Status of the system <br /> Based on the compliance criteria,the system status Is: (check one) 11 failing(to protect groundwater) ❑ an <br /> imminent threat to public health or safety(ITPHS),,0 non-compliant(monitoring Issue) 10 cbnipliant(none of the 3 <br /> previous conditions). Therefore,this-document is a: Ilio-Certificate of Compliance El.Notice of Noncompliance <br /> yst <br /> Is this sem an'EPA Class V Injectlon.Well? ❑ des ❑ no <br /> Certification. <br /> I.hereby certlfy as a state of Minnesota licensed Inspector and/or Designer I or Qualified Employee Inspector and/or Qualified Employee <br /> Designer I that I conducted an investigation that accurately determined the compliance status of this system and that my recorded <br /> observations are accurate as of this date, .-No determination of future hydraulic performance has been nor can be made due to <br /> unknown conditions during system construction,abuse of the system,inadequate maintenance,or future water usage. <br /> Inspector's name(print) �"��+ � !'1"Lw1 ri <br /> U _JQ�S Phone_ 7(o:� rl — ` (a 1 <br /> License and/or Registration Number_ _i Address 9 l <br /> Employed by <br /> Address_ � , �✓� 1 Ll,) <br /> Signature <br /> — _ Date-] `Z>^`0 <br /> Upgrade Requirements fcfen'VedfmmMlnnesotaStatutes§115.55) <br /> An ITPHS must be upgraded,rep/aced.or its use d/scontlnued with/n ten months of receipt of this notice or Within'a shorter.period if <br /> required by iota/ordinance. If the system falls to pro vide suhidentgroundwater protection, then the system raiust be upgraded, <br /> replaced, a Its use discontinued design the time required by rule or.the local oidlnance. If an existing system/s not falling as deAned in <br /> /aw,.and has at least two feet of design so!/separation,then the system need not be upgraded mpalred,replaced, or ILs use <br /> d1scont1nue4 notwithstanding any local ordinance that is more strict. 7751s does not apply to systems In shorelandareas, wellhad <br /> e <br /> protection areas, or those used/n connection lvith fogs;beverage,and lodging establishments as defined!n law. <br /> Suggested Attachment <br /> 1') Site sketch could also include:well,well setback to system,dwelling or,other buildings,.tank(s),reserved soil treatment area, <br /> surfiace`water a'nd soil`boring locations. Include as-built drawing if available. <br /> 2) Soil boring logs,showing each horizon.`Iridlcate the texture,color <br /> whether.the material is fill. ,redoxlmorphic features depth-to' bedrock,standing water and <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 /> 5) Monitoring data as appropriate. <br /> Page 2of2 <br />