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��ropertv Owner(s) � Fire No./ Parcei No. <br /> � �. �� i_.,�:��_ , ..� � �� .tti: ��. ) _�- , <br /> Svstem Comnonents (P/ease desa�be tfie sys�em mmponent�and attach slt�skef�h showfng system/ocatlon): <br /> �}�`.. 1�`s�Y�'1 ' Gc91,t �::; 1 `.��6� �:)�;� '��—� !rJ'?; � :y��,l'i t�k��=�--r !��S 1.� �� �'��'}:_": <br /> —� ' � . <br /> � I'yl I��a���'�� � �t1 i�i�� �� /v���i�.� 1 r;�c_�- � ��`a::�. <br /> What'methods w�re used to mak+e tlie determinatlons for the comuliance Insnectfon?(Note:No standa�prot�m/er/sts <br /> The fo/%wing/Ist/s not exhau.sdv�,or/n sequenda/orde�norind/cates wh/ch cnmb/nadons�may nee�ssary tn make a determinatlon) <br /> Watertight tank(s) Hydraulic Functtoning Verdcal Separatlon Distance <br /> ❑ Probed ta�k botbom. o Searched for surface outiet v • Conducted so(I borings <br /> ❑ Observed low 1lquidJevel v �Performed hydraullc test . Depth to Itmiting layer. �.-��`�'�r <br /> ❑ Examined const records I� Searched forseeping in yard 1�� Depth to s�rstem bottom �`���='1.��7 � <br /> ❑ Examined empty(pumped)tank o Chedced for badc up.in home o Dcamined records <br /> ��� ���7�� <br /> ❑ Probed outside tank for"black soil" t� Excessive ponding tn soll system/D-tio es O CGU Llmiting Layer Verificatlon <br /> o Pressure/vacuum chedc ❑ Homeowne�testimony , 'o Other <br /> ❑ Other o Examtned for surging in tank_. . <br /> • p "Black so11",above soil system 1���) <br /> o Other . <br /> Status.of the svstem ' <br /> Based on the compltance criteria,the�system status is: (cheek one) t�failing (to protecG groundwater) ❑ an <br /> imminent threat to pubiicheaith or safety(TTPHS),'� non-compliant�(monito�ing issue) � compliant�(none of the 3 <br /> previous condittons). Therefore,�thlsdocument is a: ❑•CertJflcate of Compliance ��Notice�of Noncompiiance <br /> Is this system an�EPA Class V Injectlon.We117 ❑ yes O no . <br /> Certification� � �� � � � � <br /> I.hereby certiry�s a state of Mlnnesota Ilcensed Inspector and/or Destgner I or Qualifled Empioyee Inspector andJor Qualifled Employee <br /> Designer I tfiat I conducCed an invest(gatlon that aaUrately determined the compllance status of this system and that my recorded <br /> observatlons are accurate as of this datc� �dVo determtnation.of future hydraulic perfoRnance has been nor can be made due to <br /> unknown conditlons durtng system construction,abuse of the system,inadequate malntenance,or future water usage. <br /> Inspector's name(ptint) 5�'�Gt�� 1-J .. �U.�L"��vL�J'C�5 Phone 7(0:� �- �Q1 r1 — 3��v �o <br /> L]cense and/or Registratlon Numbet 3�� Address °1�1 IL�"��1.'n 1..�. f..1.''�. <br /> Employed by,5��''�'�1�'4�1� 1�G. ' Address � . �1. 1 L1.���.._ ,_� !7. S.S�3�L. <br /> Signature `�'-'�-=.-._r,',�; �� ( ..._ , Date �l-`i� -(1 �;� <br /> �„1,parade Reauirements (derh�+dfiamM/nnesntaSta[vl�s§115.55) <br /> An ITPHS must be upg�ade+d,rep/ac�d,or/ts usr dLarondnued w/thln ten monb5s of r�relpt of d�Is notYc�or w/bh/n a shorte�.pe�lod if <br /> requ/red by/oca/orrJlnan� Ifd�e system faI/s In prov/de.sul.9`Iclentgroundwaterprot�cb'on,Ghen the sys�m m'ust Ge upyrade+d, <br /> r�p/ace�d, or/�r use dl�ndnu�d w/rih/n the tYm�r�u/red by rule or the local oirl/nance. If an exlsdng system/s not fa!//ng as detTned In <br /> /aw,.and has at/eas!`�+ro feetofdeslgn so!/sep�arot/on,tfien dre sysi�m need notb�e upgraded,re,aa/r�rep/ac�d, or/Ls use <br /> dlscondnue+d,notw/d�sland/ng any/o�cb/orr�Inanc�Ghat/s more s0�lcG Th/s does not app/y tv syst�ms/n shore/and ar�as, we//head <br /> prc�l�ct/on areas, o�Lhose use+d/m m�necb'on wJtfi f�4�d,b�ev�rage,and/odg/ng establ/shmenls as def/ned/n/aw. . <br /> Sucrgested Attachments . � .� � <br /> 1) `Site sKebch coul�also indude:weli,well setback to�ystem,,dweliing or oth.er buildings,.tank(s},reserved soii treatment area, <br /> s�ifiace w�ter and�sotl'bo�rlrig locatlons. Inciude as-butit drawtng if availa6le. ' <br /> 2) Soil boring logs,`sfiowing each�hor(zon.��Irtidl'cabe tfie texture,color,redoximorptiic features depth�to bedrock,standing water and <br /> whether the mater(al is ftll: . <br /> 3) A I(st of any.and all requlrements of tfie.locai ordinance that.are diffecent fr.om the state requiremerits referred to on this form. <br /> 4) A homeowner survey of system performance,signed by the homeowner as being factual. <br /> 5) Monitortng data as approprtate. <br /> � • Page 2 of 2 � <br />