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Property address: 1 5 01-c91,—\0 C7 4' r1 b a, 1.91 Inspector initials/Date: = <br /> l , <br /> 4. SOIL Separation—Compliance component#4 of 5 <br /> Date of installation: :,01 0 Unknown Verification method(s): <br /> ShoorelandiWelihead protecttonlFood Beverage ❑Yes i]No Soil observation does not expire. Previous soli <br /> Lodging? <br /> observations by two independent parties am sufficient, <br /> Compliance criteria: unless site conditions have been altered or local <br /> For systems built prior to April 1, 1996,and ❑Yes 0 Na requirements differ. <br /> not located in Shoreland or Wellhead ® Conducted soil observation(s) (Attach boring logs) <br /> Protection Area or not serving a food, 0 Two previous verifications(Attach boring logs) <br /> beverage or lodging establishment: <br /> 0 Not applicable(Holding tank(s),no drainfield) <br /> Drainfield has at least a two-foot vertical <br /> separation distance from periodically ❑ Unable to verify(Sea comments/Expianatian) <br /> saturated soil or bedrock. ❑ Other(See Comments/Explanation) <br /> Nonperformance systems built April 1, ( ]Yes 0 No Comments/Explanation: <br /> 1996,or later or for non-performance <br /> systems located In Shoreland or Wellhead <br /> Protection Areas or serving a food, <br /> beverage, or lodging establishment: <br /> Drainfield has a three-foot vertical <br /> separation distance from periodically • <br /> saturated soil or bedrock.* <br /> `Experimenter, 'Other, or "Performance" 0 Yes 0 No indicate depths of elevations <br /> systems built under pre-2008 Rules;Type IV 4. l - 105,0 <br /> l,7 Sx±+c. <br /> or U systems built under 2008 Rules(7080. A. Bottom of distribution media 1 o 7.S',D <br /> 2350 or 7080.2400 (Advanced Inspector 5.6v;- 1,0 <br /> License required) B. Periodically saturated soil/bedrock Sg e g-1,s <br /> Drainfield meets the designed vertical ss�• - <br /> separation distance from periodically o separation _ 0 <br /> saturated soil or bedrock. D. Required compliance separation- <br /> Any <br /> `0r <br /> Any"no"answer above indicates the system is- *May be reduced up to 15 percent if allowed by Local <br /> Failing to Protect Groundwater. Ordinance. <br /> • <br /> 5. Operating Permit and Nitrogen BMP*—Compliance component#5 of 5 13 Not applicable <br /> Is the system operated under an Operating Permit? 0 Yes ❑No If"yes",A below is required <br /> Is the system required to employ a Nitrogen BMP? ❑Yes 0 No if"yes",B below Is required <br /> BMP=Best Management Practice(s)specified In the system design <br /> if the answer to both questions is"no",this section does not need to be completed. <br /> Compliance criteria <br /> a. Operating Permit number: <br /> Have the Operating Permit requirements been met? ❑Yes ❑No <br /> b, Is the required nitrogen BMP in place and properly functioning? 0 Yes 0 No <br /> Any"no"answer indicates Noncompliance. <br /> Upgrade Requirements(Minn.Stat§115.55)An imminent threat to public health and safety(ITPHS)must be upgraded,replaced,or its use <br /> discontinued within ten months of receipt of this notice or within a shorterperiod if required by local ordinance. tf the system is failing to protect <br /> ground water,the system must be upgraded,replaced,or its use discontinued within the time required by local ordinance,if an existing system <br /> is not falling as defined in law,and has at least two feat of design soil separation,then the system need not be upgraded,repaired,replaced,or <br /> its use discontinued,notwithstanding any local ordinance that Is more strict This provision does not apply to systems In shoreland areas, <br /> Wellhead Protection Areas,or those used in connection with food,beverage,and lodging establishments as defined In law. <br /> wV1w.pca.state.mn.tis ® 651.296.6300 • 800.657.3864 • TTY 651.2825332 or 800.657.3864 • Available in alternative formats <br />