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, � <br /> Property address: �.�/'� �'����VEs' w Inspector initials/Date: T.�e�� <br /> 4. SOid SepdPBtiOt1—Compliance component#4 of 5 <br /> Date of installation: g ❑Unknown Veriflcation method(s): <br /> 3horelandNVelihead protectioNFood rage <br /> Lodg(ng? ❑Yes ❑No Soil observatlon does nof expire. Pnavious sal <br /> obseivabons by iwo independent partes ar�suficient, <br /> Com liance crlteria: unless site condfions have been alieiod orlocal <br /> For systems built pdor to April 1, 9996,and [�Yes ❑No �guirements di�er. <br /> not locat�sd in Shoreland or Wellhead [✓�Cc�nducted soil observation(s)(Attach boring logs) <br /> Protecfion Area or not se►ving a food, ❑ Two previous verifications(Attach boring Mgs) <br /> beve�age orlo�ing establ�shment.• <br /> ❑ Not appltcable(HoMing tank(s);rro dr�Jnfield) <br /> Drainfield has at least a two-foot vertical ❑ Unable to veriiy(See CommeM�irplanatlon) <br /> separation distance from periodically <br /> saturated soil or bedmck. ❑ �her(See Comments/Ekplananon) <br /> Non-perfonnance systems built Apri19, ❑Yes ❑No Comments/Explanation: <br /> 1996, or later orfornor�-perinrrrrance ��_/ <br /> systems located in Shorsland or Wellhead ' �� g Tor s+a�/ '�p,�,,,_— <br /> Protection Areas or serving a f�od, �'" <br /> beverege, orlodging establishment.• ��:.,�y�r / <br /> Drainfield has a three-foot verticai <br /> � C l�c.-`� �.�,.,.� <br /> separation distance from periodically �3'� p��D�, <br /> saturated soil or bedrock. �� <br /> °Experimental", 'Other; or Pe►f+o►mance" ❑Yes ❑No IndiCate de ths Of elevations <br /> systems built under pie-2008 RWes;Type IV <br /> or V sysiems built under 2008 Rules(7080. A. Bottom of disMbution media <br /> 2350 or 7080.2400 (Advanced Inspector <br /> License required) B. Periodical saturated soiUbedrock <br /> Drainfield meets the designed vertical � � �� <br /> separation distance from periodicalty C. S stem se aratlon <br /> saturated soil or bedrock. <br /> D. R uired com Ifance se aration" <br /> Any "�o"answer above indicates ti►e system is *May be reduced up to 15 perc�nt if allowed by Local <br /> Failing to Protecf Groundwater Ordinance, <br /> 5. Operating Permit and Nitrogen BMP*—comp�iance component#s of s ❑Not�pplicable <br /> Is the system operated'under an Operating Perrnit? ❑Yes No If"yes",A below is required <br /> Is the system required to employ a Nitrogen BMP? ❑Yes to If"yes", B below is required <br /> BMP=6est Managem�nt Practice(s)specified in the system design <br /> If the answer to both questions is "no'; tiris section doas nof need to be completed. <br /> Com liance criteria <br /> a. Operating Permit number: <br /> Have the O eratin Permit re uiremerrts been met? ❑Yes ❑No <br /> b. Is the r uired nit en BMP in iace and ro e functionin ? Yes ❑No <br /> Any "no"answer indfcates Noncompliance. <br /> Upgrade Requirements(A9inn. Stet§115.55)An imminent threat to publk heaith and safety(lTPHS)must be upgraded,replace�/,or its use <br /> discontinued withln ten monfhs of rec�lpt of thfs rtotke or withln a shorter period if required by local ordinance,If the system is failing to protect <br /> ground weter, the system must be upg�aded,iep/aced,or its use di�onbnued a�thM the tlme required by/oca/oidinance./f an existing systerri <br /> is not failing as defined in law,and has at/east two feet of desrgn soil separation,then fhe system need not be upgraded,r�paired repleced,a <br /> its use disconHnued,nofwithstanding any local omlinance that is more strict. This provision does not apply to systems in shoreland eroas, <br /> Wellhead Protecfion Areas, or those used in connecNon with food,beverage, and lodging establlshments as deflned ln 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-lvwists4-31 r 1/24/12 ' <br /> _.- -. .. .-- Page3of3 <br />