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<br /> roperly address: 4 Z5 Count Road 6 Orono MN. 55356 Ins ector initials/Date:� 1 Z/9/2012 -4��-
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<br /> (mm/dd�yyyy) �.
<br /> . Soil Se ara ion—Compliance component#4 of 5
<br /> ate of installati n: Z, O Unknown V�riflcatlon �nethod(s):
<br /> � �� � Soil obsenrabon does nof expire.Pr+avious soil
<br /> horela�dNVellhead protsctloNFood bovarage �Yes � No observaHons by iwo independent parties are s�cier�t,
<br /> �dging? unless site cand/Hons have been alte�d or lacal
<br /> om liance criteria; �quir�ments difiFer.
<br /> rsystems builtpn�ortoApri/1, 1996, and �Yes ❑No �Conduded soil observation(s)(Attadrboringlogs)
<br /> ot locafed in ShoreVand orWellhead ❑Two previous verifications(Attech boring logs)
<br /> rotection Area or nof serving a fpod,
<br /> everage or lodging establishmer�t.• I i ❑Not applicable(Ho/ding tank(s),no drair►fiel�
<br /> rainfield has at lea t a twafoot yerU I ❑ Unable to verify(See Comments/Explar�atlon)
<br /> eparadon distance m periodi Ily ❑Other(See Comments/Explanatron)
<br /> aturated soil or bed ck.
<br /> onperformance sy'stems kuilt April , ❑Yes ❑ No CommeMsiExplanation:
<br /> '�� '�j996,orlaterorfornorr-perforrnance y �
<br /> $ystsms/ocated in Shoreland or Wellhead , (/�/'1��'G� ��U II��
<br /> Protection Areas ar senring a food,
<br /> beverag�,orlodgingestablishment: �0��l�R""i'' ��17��Z -
<br /> '[�llaln�eld has a three-foot•!ver4cal .; � �, .��,. . . �_�-- _.-_, ,., _ �,..._ ��,,.
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<br /> separation distance from periodically
<br /> satu�ted soil or bedrodc,*
<br /> ,'�xx�ehimental; "Othe�', or� °Perfomi�nce" ❑Yes p No Indicate de ths or eleva�ions
<br /> �ystems bui/t under pns-2008 Rules;Type!V • �
<br /> br V systems built under20E�8 Rules,(T080: � A. Bottom of dlstrlbudon r�edia �Q ,,
<br /> 350 or 7080.2400 (Advanced InspeCtor ,, ;
<br /> �cense required) ` : , ,� qQ
<br /> �.<.-� �
<br /> B.�.Periodicall Saturdted Soil/bedroCk / p.
<br /> �rainfield meets the designed vertical C. �S m se aratlon � �o��
<br /> p�retian distance from periodically _
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<br /> �a�l'ated soil or bedrock.,, ,t; �,, , D. R uired com liance sa arat(on*
<br /> �4n 't�no"answer above f�di�afes fhe system is *May be reduoed up to 15 percent if allowed by Lacal
<br /> �v��ig.fa protect grou�►c�atpr. Ordinance.
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<br /> 5r�;,�lperating Per,mit �ind Nitrogen BMP'`—Compliance component#5 of�5 � Not applicable
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<br /> �,r�,�s�he,system operabed un�er,-�n O,perating Permit? �Yes ❑No If"yes",A below is requi�ed
<br /> �`ls the system required to'empioy a Nitrogen BMP7 ❑Yes ❑ No If"yes",B belo�;�is,,�nequired
<br /> s; . �: ,. ±, ,
<br /> f�r;.;;,. BMP=8est Manag�e�ttt,Practice(s)apecified!n the system dssign },.� � �� . -
<br /> � � ,,. r i'.�^ c,�::. i.�,
<br /> ��lfthe ar►swer[+o both�questions is "no", this section does no!need to be comp/eted.
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<br /> `"'Lbm lisnce cr+iteria "
<br /> s�� _
<br /> ` ber: _---
<br /> �,. ,, P 9 ❑Yes ❑.Nc �,, m.
<br /> a: 0 eratin ennitnu���� uire. e�s been met? .
<br /> Have the 0 rati P
<br /> �•,,,. . � _. _ _ _ .
<br /> c�� t b;:;,sils the.re ui ed nitr en�BMP in lace and rv erl functionin ? Yes No��' ' ::_. _ . ... _ _
<br /> z'i4�y'"no"'ah w�er in�iicates'Noncompliance.
<br /> i:., .... . _
<br /> �E,���nefe R � ul�'A�'feltLs MrM:'��SYat� 1 t&55 An Immlr�ent threat to ub/ic health and saTe ITPHS must�y
<br /> uP9 eq f § ) p ty l 1 be upgraded��eplaced,or�Ta use
<br /> s � rrtinaed within ien months bf�ecelpt of thia noNce or within a shorder peNod if required by/oeal oMirt�nC�; [he system is failing.�o protect -
<br /> 3.�1g�und water;�the Sysfem must be upgraded,replaced,orits use d/sconUnued wi7hin the Hme required by/oca!wdinanca.!f an e9rlsting system
<br /> ----is-nat failing as defiped in/aw,and has at/east hvo feet of design soi/separaGon,then the system need not b��upgiaded,iepaire'tl,nep/aced,or
<br /> �wrl�y9 uSe,discantinueQ,notwithstanabng any loe�o�d/nance t,�lat is more s6rck This provision does not apply to�sysEems in shor�elend areas,
<br /> � ,�/,{A�,eUhead Protectian Areas,or.thqse used in oonnecUon wn7h food,beverage,and/odging establishments as deflned/n/aw.
<br /> 'WY.�k . . ' .. .. . , • <�l�
<br /> r�►w.p,ca.state.mn.us • 651•296•6300 • 800-657-3B64 • T1Y 651-z8Z•5332 0�800-657-3864 • Available in altemati�fonnats
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