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Property address: i S 6 4 J Inspector Initials/Date: ✓_ ` <br /> 4. Soil Separation—Compliance component#4 of 5 <br /> Date of,installation: d o o Unknown Verification method(s): <br /> sehiw <br /> orenandellhead protection/Food Beverage ❑Yes Q No Soil observation does not expire.Previous soil <br /> d <br /> g >l observations by two Independent parties are sufficient, <br /> Compliance criteria: unless site conditions have been altered or local <br /> requirements differ. <br /> For systems built prior to April 1, 1996,and 0 Yes 0 No <br /> not located in Shoreland or Wellhead in 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: ❑ Not applicable(Holding tank(s),no dralnfield) <br /> Drainfield has at least a two-foot vertical Unable to verify(See Comments/Explanation) <br /> separation distance from periodically ❑ Other(See Comments/Explanation) <br /> saturated soil or bedrock. <br /> Non-performance systems built April 1, D Yes ❑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" ❑Yes ❑No indicate depths of elevations <br /> systems built under pre-2008 Rules;Type iv <br /> ' ','. l.g'y6s-- <br /> or V systems built under 2008 Rules(7080. A. Bottom of distribution media 09,c) I, p„ <br /> 2350 or 7080.2400 (Advanced Inspector g„ -I,s <br /> License required) B. Periodically saturated soil/bedrock s c:'n -• r.0 <br /> Drainfield meets the designed vertical 1, <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 /> Falling to Protect Groundwater. Ordinance. <br /> 5. operating Permit and Nitrogen BMP*—Compliance component#5 of 5 0 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 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 0 No <br /> b. Is the required nitrogen BMP in place and properly functioning? __❑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 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 feet of design roil 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 shore/and areas, <br /> Wellhead Protection Areas,or those used In connection with food,beverage,and lodging establishments as defined In law. <br /> www.pca.state.iiltLus 6 651.2966300 ® 800.657.3B64 6 1Tf 651.282.5332 or BOO.657.3864 . Avaitable in alternative formats <br />