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FROM :WALDENWOOD FPX NO. :9529748446 Jul. 30 2007 10:35RM P4
<br /> 1/
<br /> Property Owner(s) ._ Fire No./ Parcel No, _
<br /> system Components (Please describe the system components): 2/�eiZ13 ��Z� �� y ,�u�
<br /> Mlle Ns Sy5I I= Da C�, r ,�
<br /> � � oar � � ' PL T k2 / - /00aq _ 7.-
<br /> What methods were used to make the determinations for the compliance Inspection?(Note: No standard protocol exists.
<br /> The following list is not exhaustive, not in sequential order nor Indicates which combinations are necessary to make a determination)
<br /> Watertight tank(s) Yydrauiic FugcciQninq Separation Distance
<br /> gc Probed tank bottom *,Searched for surface outlet l' Conducted soli borings .�(/y/
<br /> ❑ Observed low liquid level ❑ Performed hydraulic test 0 Depth to redox `�7
<br /> 4
<br /> X Examined const. records X. Searched for seeping in yard 0 Depth to system bottom 7-4- C/ !r\)
<br /> ✓ Examined empty(pumped) tank Checked for back-up In home 0 Examined records S a,.,
<br /> yk Probed outside tank for black soils 0 Excessive ponding in soil system ❑ County Verification Records (/,
<br /> ❑ Pressure/vaccum check Homeowner testimony 0 Other 1t. n
<br /> • ❑ Other U Examined for surging in tankn n `
<br /> DUl a-L-4"-J
<br /> G "Black soli"above soil system / ���� �)
<br /> G Other /!° 1°!(�
<br /> STATUS OF THE SYSTEM y._� r S
<br /> Based on the compliance criteria above the system status Is (check one) in compliance (functioning) D failing
<br /> (to protect groundwater) Elan imminent threat to public health or safety(1TPHS),j� non-compliant (monitoring issue).
<br /> 0 compliant(non of the 3 previous conditions). or O insufficient information to make determination.
<br /> ; Therefore, this document Is a,Certificate of Compliance 0 Notice of Noncompliance 0 Unknown compliance
<br /> SUGGESTED ATTACHMENTS:
<br /> 1) Site sketch. Suggested Items for sketch Include: well, well setback to system, dwelling or other buildings, tank(s), soil treatment
<br /> system, reserved sill.treatment area, property lines, surface water and soli boring locations.
<br /> 2) Soli 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, signed by the homeowner as being factual.
<br /> 5) Monitoring data as appropriate.
<br /> •
<br /> CERTIFICATION
<br /> I hereby certify 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 Burin. - stem construction, abuse of the system, inadequate maintenance, or future water usage.i
<br /> T A. 60._,Ti 7�3-47 .- Z63 7Inspector's name (print) A D , Phonnee n ro _
<br /> License and/or gistration Number Address ..0 Ul A. /A. f - 4 1.1 �S.-3`1(7
<br /> Employed by km's b 5o rL 71s7fAddress Al��,, e/ // /i 1/
<br /> /
<br /> Signature _ Date �( Z Co( &J
<br /> Upgrade Reaulrements (derived from Minnesota Statutes§115.55) IIIIII
<br /> An ITPHS must be upgraded, replaced, or Its use discontinued within ten months of receipt of this notice or within a shorter period if
<br /> required by local ordinance. If the system fails to provide sufficient groundwater protection, then the system must be upgraded,
<br /> rep/aced, or its use discontinued with/n the time required by rule or the local ordinance. If an existing system is not falling as defined in
<br /> law,and has at least two fcct of design so//separation, then the system need not be upgraded, repaired, rep/aced, or its rise
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<br /> protection areas, or['nose useC/ur connection with rood, oeverage, dnd lodging estaurrsnmcncs as tenet in law.
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