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^ <br /> Property address: 4380 County Road 6 Lonq Lake,MN Inspector initials/Date: I <br /> (n►i►✓dd/YYYY) <br /> 4. Soil Separation—Compliance component#4 of 5 <br /> Date of instalfation: �Unknown Verification method(s): <br /> ��"���� Soil observation does not expire.Previous soil <br /> ShorelandlWa�lhead protecdontFood beverege �Yes �No observations by two independent padies are sufi'icient, <br /> lodging? unless site conditions have been a/tered or local <br /> Com liance Criteria: �quirements differ. <br /> For systems built prior to Aprii 1, 1996,and ❑Yes � No �Conducted soil observation(s)(Attach borirrg logs) <br /> not located in Shoreland or Wellhead ❑Two previous verifications(Attech boring�ogs) <br /> Piotection Aiea or nof seiving a food, <br /> beverage or lodging establishment: ❑ Not applicable(Holding tank(s),no drai�eld) <br /> Drainfield has at least a two-foot vertical ❑ Unable to verify(See Comments/Exptanation) <br /> separation distance from periodically ❑Other(See Comments/E,cplanatbn) <br /> saturated soil or bedrock. <br /> Non performance systems built April 1, ❑Yes ❑No Comments/Explanation: <br /> 1996,or later or for non-performance <br /> systems loceted in Shoreland or Wellhead <br /> Protection Areas orserving a food, <br /> beverage,or lodging establishment.� <br /> Drainfield has a three-foot vertical <br /> separation distance from periodically <br /> saturated soil or bedrodc* <br /> Experrmental; "Other';or "Performance" ❑Yes ❑No Indicate de ths or elevations <br /> systems 6uilt under pre-2008 Rules;Type!V <br /> or V systems built under 2008 Rules(7080. A. Bottom of distribution media 24" <br /> 2350 or 7080.2400 (Advanced Inspedor <br /> License required) B. Periodicall saturated soiUbedrock 18" <br /> Drainfield meets the designed vertical C. S tem se aration 0 <br /> separation distance from periodically <br /> saturated soil or bedrock. D. R uired com liance se aration" 24" <br /> A/ly"no"answer above indicates the system is "May be reduced up to 15 percerrt if allowed by Local <br /> failing to protect groundwater. Ordinance. <br /> 5. Operating Permit and Nitros�en BMP*—Compliance component#5 of 5 � Not applicable <br /> Is the system operated under an Operating Permit? ❑Yes ❑No If"yea",A below is required <br /> fs the system required to employ a Nitrogen BMP? ❑Yes ❑No If"yes",B below is required <br /> BMP=Best Management Practice(s)specified in the system design <br /> lf the answer to both questions is"no",this section do�s not need to be comp/eted. <br /> Com liance criteria <br /> a. Operating Permit number: <br /> Haue the O rati Permit r uirements been met? ❑Yes ❑ No <br /> b. Is the re uired nitro en BMP in lace and ro �i functionin ? ❑Yes ❑ No <br /> Any"no"answer indicates Noncompliance. <br /> Up�ade Requir�nents(Minn.Stat§t 15.55)An imminent threat to publ�health ar�d safety pTPHS)must be upgraded,repleced,or its use <br /> discorrNnued within f�n months of roceipt of this rrotice or within a shorter period if req�ired by locel ortiinance.If the system is faifing tn protect <br /> ground water,the system must be upgraded,replsced,or its use disconBnued within the time required by local ordinance.!f an exlsting system <br /> is rrot failing as defrned in law,and has at least hvo feet of design soil separation,then the system need not be upgraded,repaired,replaced,or <br /> its use discontinued,noMrithstandi»g any local adin�rrc:e that is mae strict This provrsron does not epply to systems in shor�land areas, <br /> Wellhead Protection Areas,or those used in r.onnecfion with food,beverage,and bdging establishments as defined in 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-wwists4-31 • 3/16/i2 PoQe 3 of 3 <br />