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FROM : R`�S PHONE N0. : 4422091 Oct. 29 2002 01:26PM P3 �— �E1��J�lJ e /� __�Fire No./ Pa�cel No. Property Owner(s)�11��1 ._....._,.,..,.....__..... S stem Com onents (Please desc�ibe the system components and attach site sketch showing system/ocation).• (�� /z�`O �.z� " L'`�S I S'�',�%G_ �e��—., � �zs� ��-ca�i �, P G�Rn► �� J� i mo�►.�d � m, What etho were sed to make the termi ions fon c �om I' ce ins e ' ? (Note:No standard protnciol exists The following/ist is nat erhausdve, or in sequential order no�indlr,dtes which combinations may nec�ssary to make a determination) Watertight tank(s) Hydraulic Functioning VetCical Separatian Distance � Probed tank bottom � Searched for surface outlet �I ConducCed soi! borings � U Obsen►ed low liquld level ❑ Performed hydraulic test Depth to limiting layer� � Examined const. records � Searched for seeping in yard Depth to system bottom Z � Examined empty(pumped)tank � Checked for back-up in home � Examined records o P�obed outside tank for"black soil" o F�ccessive ponding in soil system/D-boxes ❑ LGU limiting l.ayer Verification ❑ Pressure/vacuum check � Homeowner testimony ❑ Othe� O Other o Exami�ed for surging in tank 0 "Black soil"above soil sy5tem ❑ Othe� Status of the s sv tem. Based on the compliance Criteria,the systerrt status is: (�heck one) ❑ failing (to protect g�oundwater) ❑ an imminent threat to public health or safety (ITPHS), 0 non-compliant(monitoring issue)�compliant(none of the 3 p�evious conditions). Therefore,this document is a:�Ce iF te of Compliance ❑ Notice of Noncompliance Is this s stem an EPA Class V Injection Well? ❑ es no Ce ification I hereby certify as a state of Minnesota licensed Inspector and/or Designer I or Qualified EmPloyee Inspector and/o�Qualified Employee pesigner I that I conducCed an investlgation that accurately determined the complfance status of this system and that my recorded observations are accurate as of this date. No determination oF future hydraullc performance has been nor can be made due to unknown conditions during system constructlon, abuse of the system,inadequate mainbenance,or future water usage. Inspectors name (p�int) JEFF SWEDLUND Phone �.�`G�S�.�/G'3 S/ License and/or Registration Number 398 Address 7?7� d�Cor�.4 /�l�E– �F�-/�� Employed by �G. Address �^�� Slgnature J �-- Date �O l�—O� UDQtadE R@C1Ui1'Efil@17ts_ �derived from Minnesota Statutes§lYS.55) An ITPHS must be upgraded, �ep/aced, or its use discontinued within ten months af receipt of h5is nadce o�within a shon'erperiod if requ/red by local ord/nance. !f the system fa/ls to pmvide su�cient groundwater prot�ction, then the sysCem must be upgraded, r�placed,or its use discondnued with/n ohe time requ/red by ru/e or[he loca/ordinance. If an ex/sdnq system is not fai/ing as defined in law,and has aC leasC two J�el'of design so/l seperatian, �hen the system need not be upgraded, repaired,replac�d, o/its use disconG'nued, notwlt�standinq any local ordinanc�e that is more strict. This does not apply to systems/n shore/ar�d ar�as, wellhead pr�ltYt/o�areas, or Chose used in conne�b�on with foad,beverage,and lodg/ng establishments as defined in/aw. Suaaested Al�achmeets 1) Site sketch could also include: well, well setback tn system, dwelling or other buildings, t2hk(S),reserved soil treatment area, surface water and soil boring Iocatlans. Include as-built drawing if avallable. Z) Soil boring logs, showing each horizon� Indicate the texture,color, redoximorphic features depth to bedrock,stdnding water and whether the mate�ial is filf. 3) A list of any and all requirements of the local o�inance that are different f�om the state requirements refer�ed to on this form. 4) A homeowner survey of system performante, signed by the homeowner as being factual_ SJ Monitoring data as appropnate. n�,.,. � ..f�