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• <br /> Property address: I l C .-,c'v G ..i Inspector initials/Date: r �r a -7 a-1( <br /> 4. Soil Separation—Compliance component#4 of 5 <br /> Date of installation: -a - , 0 Unknown Verification method(s): <br /> Shoreland/Wellhead protectionlFood Beverage ❑Yes i1 No Soil observation does not ex ire. Previous soli <br /> Lodging? t,c ►.t}�,�'� F.,�a 00, A <br /> ')-11,-;,0(7/ observations by two independent parties are sufficient, <br /> Corn',lance 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 ® 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 /> ❑ Not applicable(Holding tank(s),no draintield) <br /> Drainfield has at least a two-foot vertical 0 Unable to verify(See Comments/Explanation) <br /> separation distance from periodically <br /> saturated soil or bedrock. ❑ Other(See Comments/Explanation) <br /> Non-performance systems built April 1, [ j 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 9 7 <br /> or V systems built under 2008 Rules(7080. A. Bottom of distribution media+a ci3 Lo y t.� <br /> 2350 or 7080.2400 (Advanced Inspector sew 1. 1. <br /> License required) B. Periodically saturated soli/bedrock <br /> Drainfield meets the designed vertical s w ) ,a <br /> separation distance from periodically C. System separation , , <br /> saturated soil or bedrock. <br /> 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 III 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 Practce(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(I PHS)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, orits 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 soli 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 shorn/and areas, <br /> Wellhead Protection Areas,or those used in connection with food,beverage,and lodging establishments as defined in law. <br /> ww/.pca.State.mn.us c 651.296.6300 t 800-657-3864 • TTY 651-282-5332 or 800-657.3864 Available in alternative formats <br />