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<br /> �em��rnoonents (P/ease descnbe bye sy,stem components and attach s/te skgtch show/ng system/ocat`ion):
<br /> �# doo I>--�a�C I loov � � ��,. ]`a
<br /> 1 D"�� a G��,�,gc�
<br /> r (Note:No standard protxal ex/sts
<br /> The fol/owing/Ist is not erhaustive, or in sequentia/oro�e�nor lndicates whkh cr�mbl�at/ons may necessary to make a determinadon)
<br /> Watertig.ht tank(s) Hydraulic Functioning Vertical Separatfon Distance
<br /> � Probed tank bottor� � Searched for su�face oudet O Conducted soil bortngs
<br /> � Observed low liquid level O Performed hydraulic test Depth to limiting layer_______
<br /> ❑ Examined const, records d Searched for seeping in yard Depth to system bottom
<br /> � Examined empty(pumped)tank � thecked for back-up in home o Examined records
<br /> ❑ Probed outside tank for"biack soii" D Excessfve ponding in sall system/U-boxes O LGU Limiting layer Verificatio�
<br /> o Pressure/vacuum check �1 Homeowner testfmony ' O �Other
<br /> ❑ Other � � Examined for surging in tank
<br /> !! "Black soil"above soil system
<br /> ❑ Other
<br /> Status of the svsfiem
<br /> Based on the compliance criteria,the system status is: (check one) CI failing (to protect groundwater) O an
<br /> imminent threat to pubiic health or safety(ITPHS), ❑ non-compliant(monitoring issue) �I compliant(none of the 3
<br /> previous conditions). Therefcre,this document is a: � Certificate of�ompliance ❑ Notice of Noncompliance
<br /> Is thls s stem an EPA Class V In ection Weil? ❑ es � no
<br /> certificarion .
<br /> I hereby ce�tify as a state of Minnesota Ilcensed Inspector and/or Designer I or Qualified Emp�oyee Inspector and/or Qualified Employee
<br /> Designer I that I conduded an investigaGon that accurately determined the compiiance status of thts system and that my reco�ded
<br /> obseroations are accurate as of this date. No determination of future hydraulic performance has been nor can be made due to
<br /> unknown conditions during system construc.tion,abuse of the system, inadequate maintenance, or future water usage.
<br /> Inspector's name(print)�+��i�✓ R �z�',eym,��,� . � Phone �. -,�-65 7— �s� 8
<br /> Ucense and/o�Registration Number_1�� �
<br /> —....._....�„� Address l � �t� 2 � ,e
<br /> Employed by �. ✓ Address,�f c3 vr �t-t 7�`Z L f'i. ✓Z
<br /> Signature
<br /> � Date P/� I Y�06
<br /> UDQf dde Reauirements rderi,�ed f,r,m Minnesota Starutes t 11Sss> - � �-
<br /> An ITPHS must be uPgraded,repl�ce.y,o�iLs use dlscontinued withln ten months of r�relpt of t�5/s n�tice o�withl,h a shori�r per/od!f
<br /> repuirc�d by/oca/ordinance. If the system fai/s to.proNde sv�dent groundwater protectlon, then the
<br /> rep/aced, o�its use discondnuc�d wfth/n the Gme r�qul�+d by ruk or,the/oca�orr�lnance. If a�.erlsDn �tem must be upgraded,
<br /> /aw,and has at/east two fe+et of deslgn soi/seiaaretion, lhen the syaYem ne+e+d not be vpgraded re��pJ���olal�g��as define�d In
<br /> disconhnued, notwithstanding any/oca/ordlnance that is more strlct. Thls doPs not appty to,sy#ems in shore/and areas, we//head
<br /> protect/on areas, ar those us�d/n connertion w/th h�oa,beveiage�'apd/odging establlshment,as defined in/aw. . . ...
<br /> Suaoe�pd Attachmen,,,� _. . . . . . . . .
<br /> i) Site sketch coutd.also include:well,well setback to system,dwelling or otherbuildings,qnk(s),reserved.soil treatment area,�.
<br /> surface water and soil boring locatlons. Include as•built dra�i ng if availabie.
<br /> 2) Soil boring logs, showing each ho�izon. Indicate the texture,colo�, redoximorphic features depth to bedrock,.standing water and
<br /> whether the makerial(s filF.
<br /> .,-_ .
<br /> 3) A list of any and ail requirements of the iocat ordinance that are different fmm�the st�te requirements referred to on this form.
<br /> � A homeowner survey of system performance,signed by the homeowner as being factual. : ' �
<br /> ) Monitoring data�as appropriate. � . !��:•;.
<br /> � � . Pag�,2�of 2
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