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rroprRy a,w��a�� ..- •--•� - ----- --- . .. _ � ...._......._...._..._......._._.,...,....._........._._.........._y.._................_,.....__......_......._............._.._.._...__.__.._._._........_...._..,..,..,.___._......._._._..._ � �vstem.Comnonent�(P/ease describe the s stem components and attach slte sketch showing system/ocadon): - �► k k What methods were used to make the determinations for the�moifance in�(Note:No standard protoco/exlsts. The follow/ng list is nut exhaustive, o�/n sequential order nor Jndicates whlch combinahons may necessary to make a determ/nation) Watertight tank(s) Hydraullc Functioning Vertical Separetion Distance � Probed tank bottom � Searched for sutface outlet � Conducted soll borings ,� ❑ Observed low liqu(d level O Performed hydraulic test Depth to limiting layer �� ❑ Examined const. records � Searched for seeping in yard Depth to system bottom 3g '' � Examined empty(pumped)tank ❑ Checked for back-up in home ❑ Examined records ❑ Probed outslde tank for"black soil" ❑ Excessive ponding in soil system/D-boxes ❑ LGU Limfting Laye�Verlficatlon o Pressure/vacuum check ❑ Homeowner testimony O Other O Other � Examined for surging in tank Cl "61ack soil"above soil system ��,L 'j'av►� — ��I o Other st tus of the svstem _ eased on the compliance criteria,the system tus is: (check one)�failing (to protect groundwater) � an imminent threat to public health or safety (ITPHS),�non-compliant(monito�ing issue) ❑ compliant(none of the 3 previous conditions). Therefore,this documenfi is a: ❑ Certificate of Compliance �Notice of Noncompiiance Is this system an EPA Class V Injection Well? ❑ yes no Certiflcation I hereby certify as a state of Mlnnesota licensed Inspector and/or Designer I or Qualified Employee Inspeetor and/or QualfAed Empioyee Designer I that I conducted an investigation that accurdtely determined the compliance status of this system and that my recorded abservadons are accurate as of thls date. No determinatlon of future hydraulic pe�formance has heen nor can be made due to unknown condtions during system constructlon, abuse of the system,inadequate maintenance,or future water usage. Inspector's name (print) JOSH SWEDLUND Phone ^ 73' 3� License and/or Registration Number 25�2 Address � r � `S , Employed by v �✓� 1C� C� Address �l�Je— Signature Date de E 1 e jderlved from Minnesota Slatutes§�15.SSJ An ITPHS must be upg2ded, rep/ace�d,or!ts use discontinued within ten manths of receipt af tf►!s notrce or w/t�hin a shorier pe�iod!f required by/oca/ordinance, If the system fa1/s to pmv/de suf)`fcient groundwater protection, then the system must be upgraded, rep/aced, or its use discondnued withrn the Cime requi�d by ru/e or fhe/oca/ordinance. If an eristing system/s not fai/inq as deFned in law,and has at least 1wo feet of design soil sepa�ation, then the system need not be upgraded, repaJred,�ep/aced, or its use discontinue�d, notwithstanding any Mca/ordinance that is more strict. This does not apply tb systems/n shore/and a�s, we//head protectfon areas, or!`liose used in connection with food, beverage,and/odging estabUshments as defined in/aw. SuaQested Attachr�ents 1) Site sketch could also include: well, well setback to system,dwelling or other buildings, tank(s),reserved soil treatment area, surtdce water and soil boring locatlons. Inciude as-builk 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 requirernents refeRed to on this form. 4) A homeowner survey of system performance, signed by the homeowner as being factual. S) Monitoring data as appropriate. � Page Z of 2 E 'd z6ZE-EL6 [ZS6l puntpamg yso� e9Z �90 90 6T t�C