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. , � Property address: 2500 SIXTH AVE N Inspector initials/Date: CB I 4/13/2015 (mm/dd/YYYYI 4. Soil Separation—Compliance component#4 of 5 Date of installation: 7/18/1984 ❑Unknown Verification method(s): (mm/dd/yyyy) Soil observation does not expire. Previous soil ShorelandNVelihead protectionlFood beverage �Yes � No observaiions by hvo independent pafies are suffrcient, lodging? unless site conditions have been alfered or local Com liance criteria: requirements ditfer. For systems built prior to April 1, 1996, and �Yes ❑ No �Conducted soil observation(s)(Attach boring logs) not located in Shoreland or Wellhead Protection Area or not serving a food, ❑Two previous veriflcations(Attach boring logs) beverage or lodging establishment: ❑Not applicable(Ho/ding tank(s),no d�ainf,etd) Drainfield has at least a two-foot vertical ❑Unable to verify(See Comments/Explanarion) separation distance from periodically ❑Other(See Comments/Explanation) saturated soil or bedrock. Non-performance systems built Ap►il 1, ❑Yes ❑ No Comments/Explanation: 1996, or later or for non-performance systems located in Shore/and or Wellhead 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 or elevations systems built under pre-2008 Rules;Type!V or V systems built under 2008 Ru/es(7080. A. Bottom of distribution media 101.4 2350 or 7080.2400 (Advanced Inspector License required} B. Periodicall saturated soil/bedrock 98.6 Drainfield meets the designed vertical C. S tem se aration 2.8 separation distance from periodically saturated soil or bedrock. D. Re uired com liance se aration` 2.0 AI?y"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*—Compliance component#5 of 5 � Not applicable Is the system operated under an Operating Permit? ❑Yes ❑No li"yes",A below ls required Is the system required to employ a Nitrogen BMP? ❑Yes ❑No If"yes",B below is�equlred BMP=Best Management Practice(s)specified in the system design If the answer to both questions is "no'; this section does not need to be completed. Com liance criteria a. Operating Permit number: ❑Yes ❑ No Have the O eratin Permit re uirements been met? b. Is the r uired nitr en BMP in lace and ro rl functionin ? ❑Yes ❑ No Any"no"answer indicates Noncompliance. Upgrade Requirements(Minn.Stat.§115.55)An imminent threat to public health and safefy(ITPHS)must be upgraded,replaced,or its use discontinued within ten months of receipt of this notice oi within a shoiter period if required by/ocal orclinance.H the system is failing to protect ground watei the system must be upgraded,rep/aced,a its use discontinued within the tima required by/oca/ordinance.lf an existing system is not failing as defined in/aw,and has at least iwo feet of design soil separation,then tha system need not be upgraded,repaired,replaced,or its use discontinued,noiwithstanding any Ixa!oniinance that is more sfrict. This provision does not apply to sysfams in shoreland areas, Wellhead Profection Areas,or those used in connection with food,6everage,and lodging establishments as defrned in law. www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651•282-5332 or 800-657•3864 . Available in alternative formats wq-wwfsts4-31 • 3/16/12 Poge 3 of 3