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. Pro�perty owner(s)— '�Z�Z.-V.,�'�'>f��G �ire PVo./ Pat-cel BY�.
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<br /> svseem Components(P/ease describe the system components' nd attach sTte sketch shosving system/ocation):
<br /> � � � �, �,�'s� �� . :� �, c ��-., �
<br /> , . ..
<br /> l! ��'� , �," r� T` � 6 �!'�-�
<br /> , � �;:� �.4J . �_
<br /> Wh ' e w • e i i r �pllan .P . .
<br /> The fo/%w/ny/!st/s not exhaustiv�, o�In sequentla/o�er nor indicates iv !ch c b nat o m�ay ne�c.e�t,�ry to makera determin,a o�
<br /> Watertlght tank(s) Hydraulic Funcli��nin
<br /> � i/ertical S�paration Distance
<br /> ❑ Probed tank bottom. ❑ Searched for surface outl t
<br /> ❑ Observed low Il uid level � ' Conducted soil borings
<br /> q ❑ Performed hydraullc test Deptli to Ifmiting layer. �l.��o a�5 r
<br /> ❑ Examined const. records �! Searched for seeping in y rd 9�,
<br /> ❑ Examined empty(pum Depth to system bottom �'+`;���
<br /> ped)tank Cl Checked for bael<-up.In h me ❑ Examined r�cords "���u
<br /> ❑ Probed outside tank for"black soil" � Excesslve ponding(n soll stem/D-6oxes ❑ CGU Limitin� Layer Verification
<br /> ❑ Pressure/vacuum check O Homeowner testimon� ��' '
<br /> y , o r���; �'y�}��N,•� Other
<br /> ❑ Other ❑ Examined for surging In nk
<br /> � � "Blacksoil".above soll sy m �{�c.� ��,�P
<br /> O. Other '��4s�c.�.5. �
<br /> Status of the svs�em
<br /> �ased on the coenp[iance criter�a,the system�tatu�is: (che k one) � failing (to protect�groundwater) ❑ an
<br /> imminent threat to public health or safety(ITPHS),�� nori=complia t(moriitoririg issue) C] compiiant(none oP the 3
<br /> previous conditions). 'i'herefore,.this�docurnent is a: ❑.Certifi e of�Compliance ■ Notice of Noncompliance
<br /> Is this system an EPA Class V Inj�ction Well? ❑ eS ❑ o
<br /> CertifiCatiot�. . °
<br /> I.hereby certify as a state of Mlnnesota Ilcensed Inspector and/or Deslgner or Qualified Employee Inspector ancf/or Quaiified Employee
<br /> Deslgner I that I conducted an invest(gatlon thaf accurately determfne�l the complfance status of this system a��d that my recorded
<br /> observations are accurate as of thls date. •No determfnatlon of futur-e hyd ulic pertormance has been nor can be made due to
<br /> unknown condittons during system constructlon,abuse oP the system,inad quate maintenance,or future watet�usage.
<br /> Inspector's name (pr(nt) � '
<br /> License and/or Reglstradon Numbet ��'}� • Phone_ 7(�"� r- ��� r. �y ���
<br /> Address �y4��-ti'"p q,•� � ,��
<br /> Employed by - l� � Address 1 �,
<br /> Signature �,. �� ,__�^�
<br /> llpqrade Requirements �(,denvedfromM/nnesotastatutes�115.55) Date_t l-a�}�p�
<br /> An ITPHS must be upgradc-�d,�p/ac�d o�ILs use d�scont/nuc�d�y/th/n tem m �ths of�e-�elpt of th/s notice or within a shorte�.pe�iod if
<br /> required by/oca/ordinance, Ifthe system fal/s tn pro�ide su�c%ntground a�er prot�ct/on, then the
<br /> rep/aced, or/Lr use discon6'nucid sv/tfi/n b5e time requlred by ru/e or.the/oca orrl/nance. If an e�lst/n rystem�,nust be upgraded,
<br /> /aw,.and has at/east lcvo f�t of deslgn sof/sepa�ation,then the system n not he upg�aded repa��reP/a��or�9 es defined in
<br /> discont/nued,notw/thstand/ng any/oca/oro'inance that/s more strict. This es notapp/y to systems/n shore/and a�eas, we//head
<br /> protection areas, or h5ose use�d/n cnnnecCion with foqo,beverage,and/odg g establ/shmenls as defined In/aw.
<br /> Su�qested.Attachment�
<br /> 1) "Site sketch could also fnc(ude:well,well setback to�ystem,dwelling or ,ther.buildings,..tank(s),reserved soil treatment area,
<br /> surfiace�waEer and soll'boring locatlons. Incfude as-built drawing ff avall 61e. '
<br /> 2) So(I bor(ng logs,stiowing each horizbn.`Iridfcete the texture,color,redo Imor��tilc features depth to bedrock,standing water and
<br /> whetlier.the material Is flll.
<br /> 3) A Ilsr oP any and all requfrements of the.local ordlnance tt�at.are cliffer.en fr.om tfle state requirements referred to on this form.
<br /> 4} A homeowner survey of system performance,signed by the homeowner s being factual.
<br /> 5) Monitoring data as approprfate.
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