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Properly address: 2450 Count�l Rd.6 Inspector Inktats/Dale: 1 7/812018 <br /> (rrx►✓dd�Ys9'Y1 <br /> 4. Soil 5eparation—Compliance component#4 of 6 <br /> Date of instaliation: 1H/1985 ❑Unkrrovm VeriOcation method�s): <br /> �m���� SoN observadon doea not expiro.Prevlous s�l <br /> odg n'g?dlWellhead proteetloNFood beverege �Yes �No obBerveNo/Is by!Nro Independent pa�UeB are suHklent, <br /> uMess sdte condltba►s have 6aen elteisd or kca/ <br /> Complfance criteria: requi�eme�►tsdllJ�r. <br /> For sys(ems bulfl prlor to Ap�N 1, 1898,and �Yea ❑No �Ccnducted cdl obtervation(s)(Affach balnq bga� <br /> not Ixated!n Shorelend or WellNead ❑Two prevlous ve�tllcadona(Atfach bafnv bOs) <br /> Proteotlon A�ea ornot serving a fond, <br /> beveiape or lodglrtg estebqshment ❑Not appflcable(F�nD tank(�.m drelMlelap <br /> Drainfleld hes at least�lwo-foot vertical C]une�e co�e�y�co�»,►w�w.� <br /> separatlon distance irom pe�iodtcaily ❑pther(s�ea co�py„eqa,) <br /> eaWrated sdi or bedrock. <br /> Na►-ped�o►mance systems bul�f Apd/i, ❑Yes ❑No CommentslExplanation: <br /> i99Q,orlah�rorfornon-pariamance <br /> syatems locafed iir Sho�efand or WeMhead <br /> ProtecBon/beas oraervinq a food, <br /> beverage,a lod8ing eatab!lshment: <br /> Drair�field hae a ihree-foot verUcd <br /> separeHai distance from periodiceAy <br /> saturated soA or bedrock.* <br /> •ExperimeMal", Other",or 'Pe�famance" p Yes ❑No indiaate de ths or elevations <br /> sy�ems bu�t underpre-2008 Rules;Type IV <br /> or V systems bWlt c�ler 2008 Rules(7080. A. eoriom of di�ullon med� 102.3 <br /> 2350 or 7080.2400 (Advanced Inspedor <br /> Licen6e required) B. Periodica sad�rotsd sowbedrodc 88.8 end 98.6 <br /> Orai�ield mests the designed vertfcel C. S ee tbn 3.7 and 3.8 <br /> separation distance from pedod�ally <br /> satureted soll or badrodc. D. Reauired camolianae s�eretbn• 2.0 <br /> Any"no"answer above lndlcates the system!s '�y be reduced up to 18 percant if abowed by Locel <br /> falling to protect groundwater. Ordinance. <br /> 5. Operating Permlt and Nitrogen BMP"'—Compliance aomponent#g of 5 �Not applicabla <br /> Is the system operated under an Operadng Pertnit? ❑Yea ❑No If"yes",A balaw Is raqutred <br /> la tho syetem required to anpby a Nitrogen BMP? ❑Yea ❑No 1/"yes",B below ia roqulrod <br /> • BMP=Best Menegement Practice(s)apec�ied!n the syslem de�gn <br /> If the answar to 6oU�queallons is"no';th/a sectlon does not need tn be oompleted <br /> Compiiance cribri� <br /> a. Operatfng PermR number: <br /> Have the O rapn Pertnft r ulremerda been met? ❑Yes ❑No <br /> b. Is the red nitro n BMP in sce and tunctbn ? Yes No <br /> Any"no"answer Indlcate�Noncompllanca <br /> u�na.rt.c,u�roments r,�nn.s�a��i�s.s61 a�r�nsn�n�oer a w�no►�n�a�a mp++s�muar ae uio�aed,►daao.d,a x��e <br /> diaoontlnwd wkhln ten monfhs otnos�}ot af Nda noNos or wNhln e+hater pertod�f roqufrod bybal a�rrinencs.J/N�s ay�sNm/a/e6h►g(io�otecf <br /> pround watsr,Elte sYB�em muaf be upproded,roplaosd,or da use decontMued wNhln NJe 44ne►eQvrksd 6Y bcal o�dNp�nc�.M an wtbfkp ayslam <br /> k rat IeM�y aa defrred in law,and hes at leeat hvo Aaet of dsaip►aoll aeparsUa►,�en ths ayafsm nsed not be�edsd roPabed,►eP/eoed,e► <br /> f�we�ocMlrwed,noAvlfhata►dhp any baa/adlnanw Uwt Is mae ahfaf.TMa provlelort doa�at apply fo syatans&�ehadend aisaa, <br /> WeDhead Protxflon Aree�,orllno�ussd M crorr�ecdor►wYh toa�beve/eps,and fotl�np eateb6ahms�a aa dslMed!n law <br /> www.pcastate.rt�.us • 651•2%-63a0 • a00�bs7•3864 • TTY 651-282•6332 or 800-657•3!W • Avallable b al0emattve formats <br /> wq•wwlsts4•31 • 3/ibl 12 Pqqe 3 0/3 <br />