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06130/2088 21:47 7634975011 SPTESTINGINC PAGE 04/07
<br /> ' G�r�pnrl'r Owner(s)- ,G�����1�7i'�i�s� .
<br /> �—��_..,1�1re No./ IParcol Na.
<br /> _.._....w__.._......---T.._.�._.�.2�0.�._._4:�'��.':� . �/�::�%� ��.�'�. .
<br /> ._.�.._.� ,�...._..._�..,.,
<br /> 5 stein �Corv� onertrs(P/eas�des�ri'be tfie sy$Eem com o�ents� �',��.~""__....._.�....�.�....,.,,Y„_,�_..
<br /> p �vd at�'ach sfl�sket'�h showfirg sys��m/oc�tlon);
<br /> —j�-����" 1 t7 v a,qa c.�P r��� ' . •
<br /> �, . ''�� 1 - � � 'Qi_I
<br /> ��,� . �-�r-�-� _: �U�\ .. . � � �
<br /> �.1�� ��t� ���:._..�. � � y� �
<br /> 1N���nel,�h+�s� rn«��[a�.k�th4 c[�F�,� I� , �� � , , . ' . ., . , ..� ._
<br /> Tlae lol/ow/ng/lstl.s note�hatrstt�tre; a�ln sc�quentla/orde�orl����'vh�n�/��S�aj,n�N���°���ke{�detemin�on
<br /> )
<br /> wa�ertlght zank(s) Flyairaullc Func�fo�png �
<br /> VertqraY Separation �i��nc�
<br /> o Probed tank boltbm. ❑ Se�rclied Far suiface outlel• '
<br /> ❑ Observed low II Uld fevel � � 'Conductecl soil horinr�s
<br /> q 4 �PerFq�mecl hydraullc tesl• Deptli to Ilmiting laye�. av���'�le y
<br /> C� Dcamined const.records �1 Searched for�seeping In yard ?la
<br /> R� F�caminec!em � � p�p�t°SYstem bol•lbm�+ �,�'S�4N4
<br /> p y(pumped)tanl< q Checked Pnr bacic u�,ln hom� � , ,
<br /> Q Probed oulside lank fo�"hlacic soll" � � � �amined re�co�ds 3,�t � y,w
<br /> � F�ccesslve ponding In sall syslem/D boxes ❑ LGU Llmilin�L.ayer V�•��'�j�"�1�?1.�,
<br /> o Prc,Ssuce/vacuum check Q I-�omeowner 1:es t lmony ., , �
<br /> ❑ Otl�er �� OEher
<br /> � • a Examined for sui�ing In tdnlc r��
<br /> ��'�'��S 'PJ W1�Q�� �,� � "�lack svli'��hovo soil syskem ��
<br /> 4��'��?..� �� , Q, Okher �
<br /> Stat�s,of�h�s stE -
<br /> A ���Y '
<br /> ��seci ooi Xhe cornpl�anca cx��erB�a,t1���sy�reraa sha�Us�s; (check one) ,❑ Falling,(to protecG grnundwater) ❑ an
<br /> imminenl threat to public h�alih,or sai'efy(�i'pNS),�CI non=mmpliant�(morit�oriny issue) �cbmp)ianC(none oFthe 3
<br /> previous conditlons). 7henefare,.tltis.do�:Uaxtent I's a: f�.Cerlificat�e of�Compliance CI�Notice�of N'oncompliance
<br /> S�fihis s steet��an'��PA Class'�][ '�e�Inr�.QAleIA� O es �� no '
<br /> Ce` rlifr�atio�. - � . ., ; . ,
<br /> � � �
<br /> I.hercby Gettl(y as a state oF Minncsoi� Iltensed�Tnspector and/or Deslgner I or Quallfled�mployee Inspecfior ancl/or Qualifed Employee
<br /> Deslgner I t�iat I condurted an Inves4igatlon thal:acc�irately determined the compllance sl:atus of thls sy�tem and iliat my recoi�ded
<br /> observat(ons�re accurakc as af this d�te, .�N�d�termin��lon oFt'utui�e hyclraulic FerForm�nce has�een nor c<�n be made due to
<br /> unicnown condlUons during system constructlon,a�use oP the sysl-em,Inadequate rndinle�ance,or future water usage.
<br /> Inspeclnr's name(p�lnl•) c r?�.��C�_Y�,����— ' � �}O�� � e� J
<br /> r 'J��,_It '•,�y� Phone�'�.�J��—L�.yZV-�O�_1
<br /> Llccnse and/or Regfstratlon Numbel-.._,,�'.� � �ddress�� ,,,, ' �- � L
<br /> Employed bY - � , � . . �•' �,"��•
<br /> Acldr�ss__ �.� ti y�,
<br /> Slgnal•ure y; -`.^1_ ��'����,,
<br /> U r�de Re u1 �men1.'5 ,(,der/veAfrornM/rrnesataStatuh:s�6115.55� naLe J a- .rp `
<br /> An.1TPffS must be u,ograded,r�p/ac�d,,or l�use d/scbnt/nued wrrhln l�n manths ofr�ce/pt of t/�/s nadce or wltfi/h�a shorrer.
<br /> �7r�/��y/ar/or�Ir�ance, I�b'i�system fa!!s tn prvv�de su�clenrgroundwa�rpmc`eciyon,t/�en the . l��iod/f
<br /> rep/accid, or!►s use discon�'nued w�t5'i'!n dje trme nequl�o'by�tule or.t/ie/oca/arz�/nanc�e rfan�i�ern �teR7 taiustl�e�upgraded,
<br /> lary,.and has arle,asr hvo feet oFdes/gn so���p�raUon,�fien O�ie,s r 9�n�Is not falling as defined/n
<br /> disrnntlnue�d,notr�/t�`istand/ng any/oca/oir/jnance 65�tls more str����s�dQes n�u�r����s�hor�l/a d are��s, wel/head
<br /> profecG'r�n ar�as,o�tfiose ris�d tm m�necd'on iy/t/i%nqd,b��era ppY � �
<br /> . g�and Jodg�ng estab//shmenGs as de�Tned fn/aw, .
<br /> S- uaQeste_ d,A ac e t ,. � �
<br /> 1) �"Site sl�etch cou(d also lnclude;uvell well setback tq SyrStem,dwelling or otl�,er hulldin s.tank(�)
<br /> s�i'�aco inr�Eer a'nd�so�f`boring locatlans, Include a9-bulll'diawlhg If avalla�lc. - 9 '� � � ;reserved soil treatment arc�,
<br /> Z) Soll boring 1❑g;,sliowing each�l�orizon.�Yr1dIc�L�e tlie'texture,calor,redoximor��lilc f�lures depth�to bedrocic,standing water ancl
<br /> whell�er.Ll�e matertal Is flll.
<br /> 3) A Ilst oF�any,aiid al! requlrements oF the,local oi•dlnance that.eire cIICFecenl•fr�vm��re sl•ate�requlrements referred to on th(s form,
<br /> �4) A homeowner survey oi'system perTormance,slgned by the homeowner es bel�g factual.
<br /> j) Monftoring d�l•a as approprl�te. � �
<br /> ' Page 7 oF� . ,
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