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� « , , , � , � Property address: 4225 County Road 6 Orono Inspector initials/Date: � . . _ _____— - -__ _ (mrNdd/yYYY) 4. Soil Separation - Compliance component#4 of 5 Date of installation: � Unknown Verification method�s): (mMdd/yyyy) ShorelandNVellhead protectioNFood beverage Soil observa6on does not expire. Previous soif lodging? ❑ Yes � No observations by two independent parties are su�cient, unless site conditions have been altered or local Compliance criteria: requirements ditfer. —_ __ ____— For systems burlt prior to April 1, 1996, and ❑Yes ❑ No ❑Conducted soil observation(s)(Attach boring logs) not locafed in Shoreland or Wedhead Protection Area or not se►ving a food, ❑Two previous verifications(Attach boring logs) beverage orlodging establishment: ❑ Not applicable(Ho►ding tank(s),no drainfreid) Drainfield has at least a two-foot vertical ❑ Unable to verify(See Comments/Explanation) separation distance from periodically ❑Other(See CommentsiExplanat;on) saturated soil or bedrock. Non-pe�formance systems builtApril 1, �Yes ❑ No Comments/Explanation: 1996, or fater or for non-performance systems located in Shoreland or Wellhead Protection Areas or serving a food, beverage, orlodging establishment: Drainfield has a three-foot vertical separation distance from periodically saturated soil or bedrock." "Experimental'; "Other', or "Performance" ❑Yes ❑ No Indicate depths or elevations systems built under p�-2008 Rules; Type N or V systems built unde�2008 Rules(7080. A. Bottom of distribution media -- --- —_ _ _ 2350 or 7080.2400 (Advanced Inspector � License required) B. Periodically saturated soil/bedrock � 36" Drainfield meets the designed vertical C. System separation 36" separation distance from penodically ---—� saturated soil or bedrock. D. Required compliance seQaration' --- -—-- --- __ - - 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*-Compliance 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=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. Compliance criteria _ _ - - _---- --_- , a. Operating Permit number: � ___ __ ❑ Yes ❑ No Have the Operating Permit requirements been met? b. Is the required nitro�en BMP inplace and properly functioning? ❑Yes ❑ No Any "no"answer indicates Noncompliance. Upgrade Requirements(Minn. Stat.§f 15.55)An imminent threat to pu6lic health and sefety(ITPNS)must be upgraded,replaced,orits use discontinued within ten months of recerpf ol this notice or within a shoRer period if nsquinsd by local ordinance.If the system is failing to protect ground water,the system must be upgraded,replaced,or its use discontinued wilhin the time required by local ordinance.lf an existing system is not failing as defined in/aw,and has at feast two feet of design soil separatron, then the system need nol 6e upgraded,2paired,replaced,or its use discontrnued,nofwithstanding any loca!ordinance fhat is more strict. This provision does not apply to systems in shoreland areas, We/lhead Protection Areas,or those used in connection with food,beverage, and lodging esta6lishments 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-wwPsts4-3 f • 3/16/12 Page 3 of 3