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ProPerty address: q 0 N 0. S1�p , , Inspector initials/Date: `' {o <br /> 4. Soil Separation-Compliance component#4 of 5 <br /> Date of installation: a 0 S a 0 Unknown Verification method(s): <br /> Shhoorrelagndlwelthead protection/Food Beverage 0 Yes Q No <br /> Lodgin <br /> Soil observation does not expire. Previous soil <br /> observations by two Independent parties are sufficient, <br /> Compliance criteria: unless site conditions have been altered or local <br /> For systems built prior to April 1, 1996, and 0 Yes 0 No requirements differ. <br /> not located in Shoreland or Wellhead 0 Conducted soil observation(s) (Attach boring logs) <br /> Protection Area or not serving a food, <br /> beverage or lodging establishment: ❑ Two previous verifications(Attach boring logs) <br /> 0 Not applicable(Holding tank(s),no drainfield) <br /> Drainfield has at least a two-foot vertical 0 Unable to verify(See CommentsrExplanalIon) <br /> separation distance from periodically <br /> saturated soil or bedrock. ❑ Other(See Comments/Explanation) <br /> Non-performance systems built April 1, IA 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 /> "Experimental" "Other" or "Performance" 0 Yes 0 No indicate depths of elevations <br /> systems built under pre-2008 Rules;Type IV <br /> Q <br /> or V systems built under 2008 Rules(7080. , 3 544.s <br /> A. Bottom of distribution media - a A ,, <br /> 2350 or 7080.2400 (Advanced Inspector • <br /> License required) B. Periodically saturated soil/bedrock 5S r 2,-a <br /> Drainfield meets the designed vertical s <br /> separation distance from periodically C. System separation y g, _ 3;°� <br /> saturated soil or bedrock. <br /> D. Required compliance separation` <br /> Any"no"answer above indicates the system is <br /> Failing to Protect Groundwater. *May be reduced up to 15 percent if allowed by Local <br /> Ordinance. <br /> 5. Operating Permit and Nitrogen RMP*-Compliance component#5 of 5 El Not applicable <br /> Is the system operated under an Operating Permit? 0 Yes 0 No If"yes",A below is required <br /> Is the system required to employ a Nitrogen BMP? 0 Yes 0 No if"yes", B below Is required <br /> BMP=Best Management Practices)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 0 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 shorter period H required by local ordinante. if 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 en existing system <br /> Is not falling as defined in law,and has at least two feet 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 /> www.pca.state.mn.us 651.296.6300 0 800.657.3864 TTY 651.282.5332 or 800.657.3864 . Available in alternative formats <br />