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FROM : 'YS PHONE N0. : 4422091 Oct. 03 2002 01:21PM P3 � _ � P�operty Owne�(s)� � ¢ �� l"o Fire No./ Parcel No. , Svstem Co�oonents (Please describe the system compo ents and attach site sketch showing system/ocaHon): � — �E i �/ � —�� s,I�!IO ..nc��'f�� /7F��=+vt 7 -- � �^ What tftet ods were used to make�e determinaUons for e tomoliance ins�ec�on� (Nate:No standard p�ot�coleX%sL� The fol%wing Ustis notexhausb►�, or in sequentia/arc�er norindicat�s whkh canbinatians nlay necessary t�make a determ/nadon) Watertight tank(s) Hydraulic Functioning Vertical Separation Distance � Probed tank bottom � Seard�ed for surface ouHet � Conducted soil borings � O Observed low liquid level O Performed hydraulic test �epth to limiting layer�., � Fxamined const records � Searched for seeping in yard 'DepCh to system bottom o�' � Examined empty(pumped)tank o Checkeci for badc-up in home � Examined records O Probed ouCside tank for"biack soil" O Excessive ponding in soil system/D-boxes ❑ LGU Limiting l,ayer Verification o Pressure/vacuum check � iiomeowne�testimony o Other ' o Other ❑ 6camined fior surging in tank � ��' ��'��,f' � �y,�,d o "Black soil"above seil systern ❑ OCher Status of the svsten� Based on the complianae criteria,the system status is: (check one) ❑ failing (to proF.ect groundwater) 0 an imminent threat to public heafth or safety(ITPHS), ❑ non- mpliant(monitoring issue)�compliant(none of the 3 p�evfous conditions). Therefore,this documen#is a:�Certificate of Compliance �IVotice of Noncompliance is this sys�em an EPA Ciass V Injection Well? ❑ yes no Certifica�ion I hereby certify as a state of Minnesota licensed Inspector and/or Desfgner I or Qualified Employee Inspecto�a�d/o�Qualified Employee Designer I that I conducted an investigation that accurately determined the compliance status of this system and that rtry recorded observaiions are accurate as of this date. No determination of future hydraulic performance has been nor can be made due to unknown conditions during system construction, abuse of the system,inadequate maintenance, or future watier usage. Inspector's name(print) JEFF SWEDLUND Phone_�Z-GS7�'�v39� Llcense and/or istration Number . 398 Address_ ��% s� � ,�1�.� Employed by � � Address ��'I� Signature Date �� U�arddeReclUirelt�gllts [der/vcdfromMlnnesotaStahutes§115.55) An l7PHS mc�-be upqrdded, �plaaad,or its us�dis�nlrnued withln ten months oirereipt of hhis notias or with>n a shat�r period� �+qulred by/ocal ord/nanc�. If the system fai/s!n provide sufFicientgroundwater prot�tlan,therr the system must be upgrader/, replac�or fir us�e discondnued within d�e d'me required by rule or the local orrlinari�e. If an excsbng system is not failing as de/9ne�d in /aw,sad has st I�ast Mro feet of dPsign soil separatlon, then the system necid not be upgraded, repair�d,rep/ac�ed, or/L use dismnd�ued,notwitfisbnd�ng any/aca/adinanc�thatis more strrcC This does nvtapply to systems in shore/and a�s, wd�head protE+ction a�as, or those use�d in avnne�ction w�h iecd, deve�aq�and lodging establishments as dc�fined in law. Suaaested Altachments i) Site sket�h could alsa Include:well,well setback to system,dwellfng or other buildings,tank(s),reserved soil treatmern area, surtace water and soil boring locations. Include as-built d�awing if available. 2) Soil boring logs,showing each horizo�. Indicate the texture,color, redobmorphic features depth to bed�oc�,standing watier and whether the mate�el is fl(l. 3) A list of any and all requirements oF the iocal ordinance that are different from the state requirements referred to on this form. 4) A homeowner survey of system performance, signed by the hom�wner as being factual. 5� Monitoring data as appropriate. • Pano � nf�