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, , Inspector initials/Date: Property address: 4. Soil Sepa�dtion—Compliance component#4 of 5 Date of installation: ❑ Unknown Ver�cation method(s): ShorelandNVellhead protectioNFood Beverage �Yes ❑No 3oi1 obse►vation does not expire. Previous soil �odging7 observations 6y two independent padies aie sufficient, Com liance c�iteria: _ _ _ unless site conditions have been altered or local requirements differ. For systems built prior to April 1, 1996,and ❑Yes ❑ N� � �onducted soil observation(s)(Attach boring logs) not located in Shoreland or Wellhead Prntec6on Area or not serving a food, ❑ Two previous veriflcations(Attach bonng logs) beverage or lodging establishment: ❑ Not applicable(Holding tank(s),no drainfield) Drainfield has at least a two-foot vertical ❑ Unable to verify(See Comments/Expianation) separation distance from periodically ❑ Other(See Comments/F�cplanation) saturated soil or bedrock. Non-perfom►ance systems built Apri11, ❑Yes ❑No Comments/Explanation: 1996, or later or for non performance systems located in Shoreland orWellhead Protection Areas or serving a food, beverage,or lodging establishment: Drainfield has a three-foot vertical separation distance from periodically saturated soil or bedrock.' "Experimental", "Other', or "Performance" ❑Yes ❑ No IndiCate de ths of elev8tions systems built under pre-2008 Rules;Type IV A. Bottom of distribution media or V sysfems built under 2008 Rules(7080. 2350 or 7080.2400 (Advanced Inspector License required) B. Periodicall saturated soiUbedrock Drainfield meets the designed vertical C. S stem se aration separation distance from periodically saturated soil Or bedrock. D. Re uired com liance se aration� Any"no"answer above indicates the system is *May be reduced up to 15 percent if allowed by Local Failing to Protect Groundwater. Ordinance. 5. Operating Permit and Nitrogen BMP*—comp�iance component#5 of 5 ❑ Not applicable Is the system operated under an Operating Permit? ❑Yes ❑ No If"yes",A below is required Is the system required to employ a Nitrogen BMP? ❑Yes ❑No If"yes",B below is required BMP=6est Management Pracfice(s)specified in the system design !f the answer to both questions is "no", this section does not need to be comp/eted. Com liance criteria a. Operating Permit number: ❑Yes ❑No Have the O eratin Permit re uirements been met? b. Is the re uired nitro en BMP in lace and ro rl functionin ? ❑Yes ❑ No Any "no"answer indicates Noncompliance. Upgrade Requtrements(Minn. Stat.§115.55)An imminent threat to public health and safety(ITPHS)must be upgraded,replaced,or its use discontinued within ten months of receipt of this notice or within a shorter period if required by local ordinence.If the system is failing to protect ground water,the system must be upgraded,replaced,or its use discontinued within the time required 6y local ordinance.If an existing system 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 its use dlscontinued,notwithstanding any local ordinance that is more strict. This prov/sion does not apply to systems!n shaeland areas, We/lhead Protection Areas,or those used in connection with fo0d,beverage,and lodging establishments as defined in law. www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in altemati�Qge 3 of 3 wq-wwists4-31 • 1/24/12