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rropC��y vw�«�� ..- •--•� - ----- •-- � ....�._�.............._........_....._._...._.__......._._.........,M._...._._.._.,......_.._.._.................�......__......_......__.........,..._.._.._..__�....._.�...._........_.......,,......__.._......_..ti_._ Sy�em Comnonents (Please describe the system components and attach slte sketch showing system locat/on): — � f'� � What methods were used to make th determinations tor the comaliance insoectioo? (Note:No standard protornl exlsts. The following list is not exhaustive, or In sequential order nor indicates whlch combinahons may necessary to make a determ/nation) Watertight tank(s) Hydraulic Functianing Vertical Separetion Distance � Probed tank bottom � Searched for surface outlet � Gonducted sall borings ��,1 ❑ Obseroed low liqu(d levei ❑ Performed hydraulic test Depth to Iimiting layer p Examined canst. records � Searched for seeping in yard Depth to system bottom 3g '' � Examined empty(pumped)tank ❑ Checked for back-up in home ❑ Examined reco�ds ❑ Probed outside tank for"black soil" o Excessive ponding in soll system/D-boxes ❑ LGU Limiting Layer Verlfication ❑ Pressure/vacuum check ❑ Homeowner testimony O Other O Other � Examined for surging in tank ❑ "Black soil"above soll system '��,C, '�'av►k — �� ❑ Other tus of the s stem Based on the c�mpliance criteria,the system s tus is: (check one)�failing (to protect groundwater) ❑ an imminent threat to public health or safety (ITPHS),�non-compliant(monitoring issue) ❑ compliant(none of the 3 previous condifions). Therefore,this document is a: ❑ Certificate of Compiiance �Notice of Noncompliance is this system an EPA Class V Injection Well? ❑ yes no Certification I hereby ce�ify as a state af Minnesota licehsed Inspector and/or Designer I or Qualified Employee Inspector and/o�QualiAed Emp(oyee Designer I that I conducted an invesdgation that accurately determined the compliance status of this system and that my recorded observatlons are accurate as of thls date. No determinatlon of futu�e hydraulic pe�formance has heen nor can be made due to unknown conditions during system constructinn, abuse of the system, inadequate maintenance,or future water usage. Inspector's name (print) ]05H SWEDLUND Phone " 73" 3 Ucense and/or Registration Number 25�2 Address � � �' a��- `S�' Employed by � �✓� �u � Address ��— - / -- Signature Date�Q ( _ �Iparade Requirements jder/ved from Minnesota Statutes§115.55) An ITPHS must be upgraded, rep/ace�d,or its use discontinued within ten manths of receipt of this nodce or w/thin a shorter period!f required by loca/orr/inance. If Che system falls to provlde su�cient groundwater protection, then the system must be upgraded, replaced, or its use discontinued within the tlme required by rule or the local ordinance. If an existing system is not faIling as defined in law,and has at least two feet of design soil separad"on, then the system need not be upgraded, repalred,replaced, o�iks use discontinued, notwithstand/ng any local ordinance that is more strict. Thls does not apply tr�systems in shore/and areas, wellhead protection areas, or those used in cnnnection with food, beveraqe, and lodging establishmentr as defrned in law. Suaaested Attachments 1) Site sketch could also include: well, weq setback to system, dwefling or other buildings, tank(s),reserved soil treatment area, surtace water and soif boring locat(ons, Inciude as-buiit draw(ng if available. �\ 2) Soii 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 requirements referred to on this form. � 4) A homeowner survey of system performance, signed by the homeowner as being factual. 5) Monitoring data as appropriate. � Page 2 of 2 � •.� �c�c_c� araca� punTPamS NsoC e9Z =90 90 6T inC