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. <br /> • Property address: 2160 6th Ave North, Lona Lake Inspector inidals/Date: JS I 7/28r2017 <br /> (mm/dd�YriY1 <br /> 4. Soil Seperation—Compliance component#4 of 5 <br /> Date of installaUon: 12/2/1966 ❑ Unknown VeHflcation method(s): <br /> �mM��� Soil observation does not expire. Previous soi! <br /> ���?"�����°"�O°d��9e ❑Yes �No obsenraSons by lwo independent parties are suRcient, <br /> g 9 unless site c�nditions have been aitered or loca! <br /> Com liance crite�ia: requirements difner. <br /> For systems built prior to Apri11, 1996, and ❑Yes ❑ No �Conducted soil observation(s)(Attach bafi►g bps) <br /> not locai+ed in Shore/and or Wellhead ❑Two previous veriflcations(Attach boring logs) <br /> Protecdon Area or not serving a food, <br /> beverege or lodging establishment.• ❑ Not applicable(Ho/ding tank(s),no drairMeld) <br /> Drainfleld has at least a twafoot vertical ❑Unable to verify(See Comments/Ezp/anation) <br /> separation distance from periodically ❑Other(See Commerrts/Eicp�anation) <br /> saturated soil or bedrock. <br /> Non performance systems builtAprill, ❑Yes �No Comments/Explanation: <br /> 1996, or leter or for non-performance Borin <br /> systems located in Shoreland orWellhead 9� <br /> Protecaon Areas orserving a/nod, 1-12"fill <br /> beveiage,or lodging establishment: <br /> 13-20" 10yr Z/Z loam <br /> Orainfield has a three-foot vertical <br /> separation distance from periodically 21-30"10yr M4 clay loam <br /> saturated soil or bedrxk." Redox�26" <br /> � <br /> "Experimenta!", "Other", or "Perfi�rmance" ❑Yes ❑ No IndiCate de hs or elevations <br /> systems built under pre-2008 RWes;Type!V <br /> or V systems built under 2008 Rules(7080. A. eottom of distribution media 30" <br /> 2350 or 7080.24� (Advanced Inspector <br /> License required) B. Periodicall saturated soiubedrock 26" <br /> Drainfieid meets the designed vertical <br /> separation distance from periodically C. S tem aration 0 <br /> saturated soil or bedrock. <br /> D. R uired c�rn ianoe retion• 24" <br /> Any "no"answer above Indicates the system fs "May be reduced up to 15 percent if allowed by Local <br /> fafling to protect groundwater. Ordinance. <br /> 5. Operating Permit and Nitrogen BMP*—Compliance component#5 of 5 � Not applicable <br /> Is the system operated under an Operating Permit? ❑Yes ❑No If"yes",A below is required <br /> Is the system required to employ a Nitrogen BMP? ❑Yes ❑No If"yes", B below is required <br /> BMP=Best Menagement Practice(s)specified in the system design <br /> If the answer to both questlons is "no", this sectfon does not need to be comp/eteal. <br /> Com liance criteria <br /> a. Operating Permit number: <br /> Have the O eratin Permit re uirements been met? ❑Yes ❑ No <br /> b. Is the uired ni en BMP in lace and ro erl functionin ? Yes No <br /> Any "no"answer indicates Noncompljance. <br /> Upgrade Requiremenb(Minn.Stat§115.55)An immir►ent threst to public hea/th and satety(ITPHS)must be uppreded,rep/eced,or fts use <br /> disc�onHnued within ten months of receipt�thls notice or wid►in a sl►ater perrod if iequl►ed by/oca!or+d/nance.If the system is feilirr�to pr�tect <br /> ground water,the system must be upgrader/,repleced,or its use di�cbntinued wlthin the Nme requi►+�d by/oca/adinance./f an exlsGing system <br /> is not falling as deflired in law,snd has at/east lwo feet of deslgn�il sepaiabon,then the system need not be upgrsdeal,repei�d,r�placed,or <br /> its use dfxor►tinued,noh�vithstanding any bca/adinance that is more strict. Thls provision does not epply to systems in shore/end areas, <br /> Wel/head Protecffon Areas,or H�ose u�d in connectfon wlth food,beve�age,and lodging esteblishments as deflned in law. <br /> www.pca.state.mn.us • 651-296-6300 • 800•657-3864 . TTY 651-282-5332 or 800-657-3864 . Available in altemative formats <br /> wq-wwists4-31 • 3/16/12 Poge 3 oj 3 <br />