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' � � •�� •�v�� • Y�rv� t\V• <br /> - 'S s em Com on nts (P/ease describe the system rnmponents and att'ach s/te sketch showing system/ocation): <br /> - � �'(� 1 C. �✓�k <br /> � � I�u✓►�p '�-A.►��,C <br /> L�m�l� �1 S°�✓�L� <br /> What meChods were used to make the determinations for the comaliance lnsoectio,�7(Note:No standard protoco/exists <br /> The fol%wing list is not exhaustive, or ln sequentia/order nor indicates which combinatians may necessary to make a dete�minatlon) <br /> Watertight tank(s) Hydraulic Functioning Vertical Separation Distartce <br /> � Probed tank bottom � Searched for surtace outlet �Conducted soil borings ,� <br /> O Observed low liquid level o Pe�fonned hydraulfc test Depth to limfting layer �� <br /> i� <br /> o Examined const. records Searched for seeping in yard Depth to system bottom�Us (� <br /> �Examined em um p � <br /> pty(p ped)tank O Checked for back-u in home ❑ Examined records <br /> ❑ Probed autside tank for"black soil" O Excessive ponding In soil system/D-boxes 0 LGU Limiting Layer Vertficatio� <br /> 0 Pressure/vacuum check ❑ Homeowner testimony 0 Other <br /> ❑ Other � Examined for surging in tank <br /> ❑ "Black soil"above soil sysfiem <br /> ❑ Other <br /> Status of the svstern <br /> Based on the comptlance criteria,the system status is: (check one) ❑ faiiing (to pr tect groundwater) O an <br /> imminent threat to public health or safery (IT'PHS), ❑ non-compliant(monitoring issue)�ompliant(none of the 3 <br /> previous conditions). Therefore,this document is a:�Certificate of Compliance ❑ Notice of Noncompliance <br /> Is this system an EPA Class V Injection Well? O yes � no <br /> �ertification <br /> I hereby certifjr as a state of Minnesota(i�ehsed Inspector and/or Designer I or Qualified Employee Inspector and/or Qualified Employee <br /> Deslgner I that I tonducted an investigaGon that accurately determined the compliance status of this system and that my recorded <br /> observations 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 construction� abuse of the system, inadequate maintenance,or future water usage. <br /> Inspector's name (print) IOSH SWEDLUND Phone r � � <br /> License and/or egi tion umber 2502 Address�JGo�� " �C9 .._ S , ���/ �QI� <br /> Employed by � � Add�es5 ��1L1L <br /> Signature Date <br /> Unarade eqUlteMelltS jderlved from Minnesota Statutes§115.55J <br /> An lTPHS must be upyraded, rep/aced,orlLs use discontlnued within ten months ofreceipt of tliis notice or with/n a shorter pe�iod if <br /> required by/oca/or�inance. If the system fails M provide su�cient groundwater p�ote+ctlon, then the system must be upgrdded, <br /> rep/aceo; or iL�s use discondnued within the Ume requi�d by iv/e or the/oca/ordinance. If an existing system is not fai/ing as deffned in <br /> law,and has at/east two feet of design soil separation, then the system need not be upgraded,repaired,rep/ac�d, or/ts use <br /> dlscoMrnued, notwithstanding any/oca/ort�inance that is more strict. This does not app/y tn systems in shor�land areas, wellhead <br /> prolpction areas, or those used in connection with food, beverage,and/odging establishments as deflned in/aw. <br /> Suaaested Attachments <br /> 1) Site sketch could also include: well, well setback to system, dwelling or other build(ngs, tank(s),reserved soif treatment area, <br /> surface water and saii boring locations. Include as-bullt drawing iP available. <br /> 2) Soil boring logs, showing each horizon. Indicate the texture, color, redoximorphic features depth to bedrock,standing water and <br /> whether the mater(al is flll, <br /> 3) A list of any and all requirements of the local ordinance that are different from the state requirements referred to on this form. <br /> 4) A homeowner survey of system performance, signed by the homeowner as being factual. <br /> SJ Monitoring data as appropriate. <br /> � Page 2 vf 2 <br /> E 'd Z6ZE-EL8 (ZS6l puntpamg ysoC eZ�b �Oi 90 EO �oN <br />