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. �stem Comoonents (P/ease describe the system cP mponents and attach site sketch showing system location : ic�SU �i� 7I y� � Tl` Zi�LZ� '—D ' /14� �S� /_�i'� �ov� S�I '�r'�/' Il/L.+4 s.,,a.methvds were used to make the determination for the comflllance insaection? (Note:No stan ar protoco exists. The fo/%wing/ist is not exhaust/ve, o�in sequentia/order nor indicates which combinations may necessary to make a determination) Wateltight tank(s) Hydraulic Functioning Vertical Separation Distance � Probed tank bottom � Searched for su�Face outleC � Conducted soil borings �1 ❑ Observed low liquid level a Performed hydraulic test Depth to iimiting Idyer�_ �� � Examined const. records � Searched for seeping in yard Depth to system bottom� l� � Examined empty(pumped) tank �Checked for back-up in home 0 Examined records p Probed outSide tank for"black soil" ❑ Excessive ponding in soil system/D-boxes ❑ LGU Limiting layer Verification O Pressure/vacuum check ❑ Homeowner testimony ❑ Other ❑ Other �Examined for surging in tank o "Black soil"above soil 5ystem ❑ other Status of the svstem Sased on the compiiance criteria, the system status is: (check one) l� failing (to protect groundwater) ❑ an imminent threat to public health or safety (ITPHS), ❑ non-compliant(monitoring issue)�ompliant (none of the 3 previous conditions). Therefore,this document is a;�Certificate of Compliance O Notice of Noncompliance Is this system an EPA Class V Injection Weli? ❑ yes �1 no __ Certification I hereby certify as a state of Minnesota licensed Inspector and/or Designer I or Qua{ified Employee Inspector and/or Qualified Employee Designer I that I conducted an investlgation that accurately determined the compllance status of this system and that my recorded obseNations are accurate as of this date. No determination of future hydraulic performance has been nor can be made due to unknown condltions during system construction, abuse of the system, inadequate maintenance,or future water usage. Inspector's name (print) JOSH SWEDLUND Phone Q�_ �7�" �-�1 � L i c e n s e a n d/o r R e g i s t r a t i o n N u m b e r 25�2 A d d re s s ��'�� " �0��' �,� �' ��-- Employed by ' f�� 1l y � C �� Address Sa6�-� _ Signature - �-e Date v� �,5� Ua4rade Reauirements jderived from M/nnesota Statutes§115.55) An ITPHS must be upgraded, rep/aced, or its use discontlnued within ten months of receipt of Chis notice or within a shorte�period if required by loca/ordinance. If the system fails to p�ovide su�cient groundwater protection, then the system must be upgraded, rep/aced, or its use discontinuer�within the time�equ/red by ru/e or the/oca/ordinance. If an exlsting system is not fai/ing as defined in law,and has at least 1wo feet of design soil sepa�ation, then the system nee�d not be upgrdded, repaired, replaced, or its use discontinued, notwithstanding any/oca/o�dinance that is mo�e strict. This does not apply to systems in shoreland areas, wellhead protection areas, o�those used in connection with food, beverage,and lodging establishments as defined in law. �uaqested Attachments 1) Site sketch could also include: well, well setback to system, dwelling or other bufldings, 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 materlal is fill, 3) A list of any and all requirements of the local ordinance that are different from the state requirernents refe�red to on this form. 4) A homeowner survey of system performance, signed by the homeowner as being faRual. S) Monitoring data as appropriate. � Page 2 of 2 Z 'd Z6ZE-ELB [ZS6l punipam� ysoC eS0 �B0 SO OE daS