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FROM : RYS PHONE NO. : 4422091 RPI-, %7 %5• %, 44PM P2
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<br /> Property Owner(s) 1 C _ /./f• 4A-.) Fire No./ Parcel No, n M' .k. �
<br /> System Components (Please describe the system components and a ach site s etch showing system location): l
<br /> /^ 4.)iS/e;Z / R
<br /> i, /114'le d -- . -# ,,,_ . ,,
<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, or/n sequential order nor indicates which combinations may necessary to make a determination)
<br /> Waertight tank(s) Hydr is Functioning Vert I Separation Distance
<br /> Pr d tank bottom Searched for surface outlet Conducted soil borings
<br /> //
<br /> Observed low liquid level Cl P rmed hydraulic test Depth to limiting layer ,Z5
<br /> ❑ mined const. records Searched for seeping in yard Depth to system bottom' '
<br /> t� Examined empty(pumped)tank 0 Checked for back-up in home ❑ Examined records
<br /> ❑ Probed outside tank for"black soil" 0 essive ponding in soil system/D-boxes Cl LGU Limiting Layer Verification
<br /> ❑ Pressure/vacuum check Homeowner testimony ❑ Other
<br /> ❑ Other ❑ Examined for surging in tank
<br /> ❑ "Black soil"above soil system
<br /> ❑ Other
<br /> Status of the stem
<br /> Based on the compliance criteria, the system status is: (check one) failing (to protect groundwater) p an
<br /> imminent threat to public health or safety (ITPHS), ❑ non-compliant(mon to ing issue) Is compliant (none of the 3
<br /> previous conditions). Therefore,this document is a: ❑ Certifi to of Compliance :i Notice of Noncompliance
<br /> Is this system an EPA Class V Injection Well?
<br /> CI yes no
<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 during system construction, abuse of the system, inadequate maintenance, or future water usage.
<br /> Inspector's name (print) JEFF SWEDLUND Phone 2—Sel, — tS75"~
<br /> License and/or Registration Number 398 Address .-.40 A - ..e- a, -- 4 .tt94
<br /> Employed 13,,q—e / ',. . R _ C Address /d )0 R%.•'e. r.; :aa ,,„ o4 06.4:,,
<br /> Signature 1 7 ��`�--�C/ llara -Q.
<br /> . Date
<br /> Upgrade Re, i r-/Bents [derived from Minnesota Statutes§115.55)
<br /> An 17PHS must be upgraded, rep/aced, 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 falls to provide sufficient groundwater protection, then the system must be upgraded,
<br /> 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
<br /> law,and has at least two feet of design soil separation, then the system need not be upgraded,repaired,replaced, or its use
<br /> discontinued, notwithstanding any local ordinance that is more strict. This does not apply to systems in shore/and areas, we//head
<br /> protection areas, or those used in connection with food, beverage, and lodging establishments as defined in law.
<br /> Suggested 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 /> 5) Monitoring data as appropriate.
<br /> Dana, 7nf7
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