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Property address: v °-A0C—s:11 '4)Evv1 _, Inspector initials/Date: <br /> 4. Soil Separation—Compliance component#4 of 5 <br /> Date of installation: I ""`, 0 0 Unknown Verification method(s): <br /> Shhorenandlwellhead protectIONFoodBeverage ❑Yes D No Soil observation does not expire.Previous soil <br /> d <br /> s e observations by two independent parties am sufficient, <br /> Compliance criteria: unless site conditions have been altered or local <br /> For systems builtprior to ®Yes 0 No requirements differ. <br /> y April 1, 1996,and <br /> not located in Shoreland or Wellhead ® Conducted soil observation(s)(Attach boring logs) <br /> Protection Area or not serving a food, ❑ Two previous verifications(Attach boring logs) <br /> beverage or lodging establishment: <br /> ❑ Not applicable(Holding tank(s),no drafnfieid) <br /> Drainfield has at least a two-foot vertical 0 Unable to verify(See Comments/Explanetion) <br /> separation distance from periodically <br /> saturated soil or bedrock. ❑ Other(See Comments/Explanation) <br /> Non-performance systems built April 1, 0 Yes ❑ No Comments/Explanation: <br /> 1998,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-2006 Rules;Type IV q u �, <br /> or V systems built under 2008 Rules(7080. A. Bottom of distribution media s; a 1. ,c>1;1„•7, ,,5 v,,,.,k, <br /> 2350 or 7080.2400 (Advanced inspector 5s } <br /> License required) B. Periodically saturated solUbedrock 5 2 1 .3 <br /> Drainfield meets the designed vertical 5e,14 2,81 , <br /> separation distance from periodically C. System separation <br /> saturated soil or bedrock. D. Required compliance separation" <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 /> 5. Operating Permit and Nitrogen BMP*—Compliance component#5 of 5 El Not applicable <br /> Is the system operated under an Operating Permit? ❑Yes El 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 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? El Yes ❑ No <br /> b. Is the required nitrogen BMP in place and property functioning? 0 Yes 0 No <br /> Any"no"answer indicates Noncompliance. <br /> Upgrade Requirementas(Minn.Stat.§115.55)An imminent threat to public health and safely(ITPHS)must be upgraded,replaced, or its use <br /> discontinued within ten months of receipt of this notice or within a shorter period if required by local ordinance.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 an existing system <br /> Is not failing 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,end lodging establishments as defined in law. <br /> www.pca,state.mn.us o 651.296.6300 a 800-657-3864 TTY 651.282.5332 or 800-657.3864 Available in alternative formats <br />