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' � .�-- i Property Owner(s)_ -J�'` �.'ti��c C�� ^ r.-� Fire No./ Parcel No. _........ _.. _.. .._.. __... _........ .__....... .... .._.. _..._...... Svstem Components (P/ease describe the system components and attach site sketch showing system locatron): � — /e�-z�' � �'t-C `7'a-� L�t I — J c� �aX �-�� ,h c--z , /c�c� <� �y��,��'�L1 What methods were used to make the determinations for the compliance inspection� (Note:No standardprotoco/exists. The fol%wing list is not exhaustive, or in sequential order no�indicates which combinations may necessary to make a dete�mination) Watertight tank(s) Hydraulic Functioning Vertical Separation Distance �Q Probed tank bottom ,� Searched for surface outlet I� Conducted soil borings �( Observed low liquid level ❑ Performed hydraulic test Depth to limiting layer �� S� � Examined const. records jtl. Searched for seeping in yard Depth to system bottom � ' L� Examined empty(pumped)tank � Checked for back-up in home �( Examined records ❑ Probed outside tank for"black soil" � Excessive ponding in soil system/D-boxes ❑ LGU Limiting Layer Verification ❑ Pressure/vacuum check � Homeowner testimony ❑ Other o Other � Examined for surging in tank ❑ "Black soil"above soil system ❑ Other Status of the svstem Based on the compliance criteria, the system status is: (check one) f�l.failing (to protect groundwater) ❑ an imminent threat to public health or safety (ITPHS), ❑ non-compliant (monitoring issue) ❑ compliant(none of the 3 previous conditions). Therefore, this document is a: ❑ Certifcate of Compliance C�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 perfiormance has been nor can be made due to unknown c�nditions during system construction, abuse of the system, inadequate maintenance, or future water usage. n 1 Inspector's name(print) L_7c ��;�Q ��.P�1,,�,y.,[f Phone "7 �° �3 --�'79 -- /S�/ � License and/or Registration Number '��^ Address Employed by � C�� -C_ Address 9 � �� si nature �ate ll� -' ,.S`° � Upqrade Requirements (derived from Minnesota Statutes§115.55) An 1TPHS must be upgraded, rep/aced, or its use discontinued within ten months of receipt of this notice or within a shorter period rf �equired by local ordinance. If the system fails to p�ovide su�cient groundwater protection, then tfie system must be upgraded, replaced, o�rts use discontinued within the trme requi�ed by ru/e o�the local ordinance. If an existing system!s nnt failing as defined in law,and has at/east hvo feet of design soi/separation, then the system need not be upgraded, repaired, replaced, o�its use discontinued, nohvithstanding any local ordinance that is mo�e st�ict. This does not apply to systems in shore/and areas, wellhead p�otection areas, or those used rn connection with food, beve�age, and lodging establishments as defined rn law. SuqQested Attachments 1) Site sketch could also include: well, well setback to system, dwelling or other buildings, 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. 51 Monitoring data as appropriate. Page 2 of 2