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� �L em Comuonents (P/ease describe the s stem mmponents and attach slte sketch showing system/ocation): <br /> ctS � y� <br /> �^ yi � <br /> �/ L ` <br /> What methods were used ta make tl�e Jetertninat�o�s for the com�ltanee ins ectio�?(Note:No slandardprotna�/exlsts <br /> The fol%wJng list is not exhaust/ve,or in sequentia/order nor indicates which comb/nations may nece�sary to make a determination) <br /> Watettighttank(s) Hydraulic Functioning Vertical Separation Distance <br /> �robed tank bottom �Searched for surtace outlet � Conducted soil borings �� <br /> ❑ Observed low liquid level ❑ PerFormed hydraulic test Depth to limitfng layer �� <br /> ❑ Examined const. records � Searched for seeping in yard Depth to system bottom_� <br /> ,�Examined empty(pumped)tank O Checked fo�back-up in home O Examined records <br /> ❑ Probed outside tank for"black soil" c] Excessive ponding in soil system/D-boxes D LGU Lim(ting l�yer VeriflcaUon <br /> o Pressure/vacuum chedc ❑ Homeowner testimony o Other <br /> ❑ Other � �Examined for surging in tank <br /> ❑ "Black soil"above soil system <br /> ❑ Other <br /> Status of the svstern <br /> Based on the compliance criteria,the system status Is: (check one) �failing (to protect groundwafier) ❑ an <br /> imminent threat to public health or safety(ITPHS), ❑ non-compliant(monitoring issue) compliant(none of the 3 <br /> previous conditions). Therefore,this document is a: ❑ Ce i cate of Compliance �Notice of Noncompliance <br /> is this stem an EPA Ciass V In ection Weil� ❑ es no � <br /> C�rtification , <br /> I he�eby certiry as a state of Minnesota ilcensed Inspector and/or Uesigner I or Qualified Employee Inspector and/or Qualified Employee <br /> Desfgner I that I conducted an investlgatlon that accurately determined the compllance srtatus of this system and that my recorded <br /> observatlons are accurate as of this date. No determination of future hydreulic performance has been nor can be made due to <br /> unknown conditions du�ing system construct(on, abuse af the system, inadequate maintenance,or future water usage. <br /> Inspector's name (print) ]OSH SWEDLUND <br /> Phone r " �- <br /> Ucense and/or Registration N mber 25�2 Address � ^ ''Z � � <br /> Employed by J►� � C� Address , <br /> Sfgnature Date 1 � <br /> Unarade EAUiI'e111e11tS jderlved from Minnesota Statutes§115.55) <br /> An 17PH5 must be upgraded, rep/aced,or Its use discontinued within trn monbFis of receipt of this notice or wibhin a shorte�pe�iod if <br /> requlre�d by/oca/ort�inance. If the system fai/s M provide sufl`lcientgroundwater prot�c�lon, then the system must be upgraded <br /> rep/ac�d, or i�s use discondnued within hhe dme rE+quiied by ru/e or the/oca/ordinance. If an exisdng system/s not fai/ing as defined in <br /> law,and has at/east Mao feet of design snil separat/on, then the sysrem ite+ed not!ae upgraded, rep�air�nep/acEy ar fts use <br /> disrnndnued, notwithstanding any/oca/ordinance that is more sh/ct. This does not app/y to systems in shore/and areas, we/lhead <br /> prnntection areas, or those used/n cnnnection with food, bever�e,and/odging establishments as defined in law. <br /> Suaaested Attachments <br /> 1) Site sketch could also Include: well, well setback to system, dwelling or other buildings, tank(s),reserved soil treatment area, <br /> surface water and soil boring locatlons. Include as-built drawing If available. <br /> 2) Soil boring logs,showing each horizon. Indicate the texture, color,redoximorphic features depth to bedrock,standing water and <br /> whether the maherial is flll. <br /> 3) A list of a�y and all requi�ements of the local ordinance that are different from the state requirements referred to on thfs form. <br /> 4) A homeowner survey of system pertormance, sfgned by the homeowner as being factual. <br /> S) Monitoring data as appropriate. <br /> � Page2of2 <br /> E 'd Z6ZE-ELB [ZS6l punjpamg ysoC d6Z � T0 GO SZ nolJ <br />