2006-P10194 - Laserfiche WebLink

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1 � � ._ ..�. ..v�� • N�L.G� �\V. .... ..........."'".. Svstem Comnonents �P/ease describe the system components and attach site sketch showing system location): � _�r / 4 C�1�rn? `�`a-✓1 l�Cs � o-o � U� �a�t� - _. R��c.1�C �✓�n� s� ewt-. What methods were used to make the determinations for the comnliance insoectiott� (Note.•No standardprotoco/exlsts. The fol%wing list is not eYhaush�ve, o�in sequentlaJ order nor indicates which combinations may necessary to make a determination) Watertight tank(s) Hydraufic Functioning Vertical Separation Dlstance ❑ Probed tank bottom �Searched for surtace outlet � Conducted soil borings �i ❑ Observed low liquid level ❑ Performed hydraulic test Depth to limiting layer �� ❑ Examined const. records �� Searched for seeping in yard Depth to system bottom�� ❑ Examined empty (pumped)tank ❑ Checked for back-up in home ❑ Examined records 0 Probed outslde tank for"black soil" D F�ccessive ponding in soil system/D-boxes ❑ LGU Limiting Layer Verification ❑ Pressure/vacuum check ❑ Homeowner testimony ❑ Other � Other Now�.t nw►tic►�tvovlcl � Examined for surging in tank �b} 0.11� ��ks � b�- � 0 "Black soil"above soil system �JQ-k �1'�S�CC�td - Sq�5 �'� 0 Other �'CcA�-�" Status of the s ste� Based on the compliance criteria, the system status is: (check one) ❑ failing (to protect groundwater) ❑ an imminent threat to public health or safety (ITPHS), ❑ non-complianC (monitoring issue)�compliant(none of the 3 n✓��iiw� n .. ,q,..I:i.�__\ TL____!_. a• • . � _ � " , �is e i ica e o ornp iance ❑ Notice of Noncompliance Is this system an EPA Class V Injection Well. ❑ yes _ no Certification I hereby certify as a state of Minnesota licensed Inspector and/or Designer I or Qualified Employee Inspector and/or Qualified Employee Designer I that I conducted an investigation that accurately determined the compliance status of this system and that my recorded observations are accurate as of this date. No determination of future hydraulic performance has been nor can be made due to unknown conditions during system construction, abuse of the system, inadequate maintenance, or future water usage. Inspector's name (print) JOSH SWEDLUND Sa- 7 :�9 �-- Phone�_ � 3" 3 License and/or Registration umber 250z Address �� D `f'� s . ��,o Q1y� Employed by S��u r�� 1N IC� C, Address Sii ►'�-2� Slgnature gl D� Date UpQt'dde ReAUI�eRte11�S jderived from Minnesota Staf�tes§115.55) An ITP/-15 must be upgraded, rep/aced, or its use discontinued within ten months of receipt of this norice or within a shorter period if required by loca/ordinance. If the system fails to p�ovide su�cient groundwater protection, then the system must be upgradc�d, rep/aced, or its use discontinued within the time�equired by rule or the local ordinance. If an existing system is not falling as defined in law, and has at least Iwo fe+et of design soi/separation, then the system need not be upgraded, repai�ed, rep/aced, or its use discontinueo', notwithstanding any loca!o�dinance that is mo�e st�ict. This does not app/y to systems in shore/and areas, we/lhead p�otection areas, oi those used in connedion with food, beverage, and/odging establishments as defined in 1aw. Suqqested Attachments 1) Site sketch could also include: well, well setback to system, dwelling or other buildfngs, tank(s),reserved soil treatment area, surface water and soil boring locations. Include as-built drawing if available. 2) Soil boring logs, showing each horizon. Indicate the texture, color, redoximorphic features depth to bedrock, standing water and whether the material is fill, 3) A list of any and all requirements of the local ordinance that are different from the state requirements referred to on this form. 4) A homeowner survey of system performance, signed by the homeowner as being factual. 5) Monitoring data as appropriate. Page z of 2 E 'd Z6zE-ELS (ZS6] punTpamS ysor eS0 =90 90 SI ��d