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Ma r, 28. 2013 1 ;45 PM �4,''�7 . No. 1514 P, 5
<br /> . Property address: �� �a0 M G�..s�r� �'�•�\� Inspector initlals/Date: `�� ��1�r;�\�
<br /> 4. Soil Separation-�compliance oomponent#4 of 5
<br /> aate of inst�llatipn: q,�;t2,-�'� p Unknvwn Veriflcatlon method(�):
<br /> Sho�landlWellhead p�obectlonl�ood 9everage �Yes �Na 5ot1 obsarvatfon do@s not explre.Previous aoll
<br /> Lodginp7 obse�va6Ans by two independent partles ero strfircient,
<br /> Com Iiance crlt�ri�: unless s;te conditrons have been altared orlacal �
<br /> requit�ments di8'er.
<br /> �'orsystems bullt prlar(o Apri11, 1�96, and []Yes ❑No
<br /> not locatedln Shoreland or Wellhead � Conducted soil obsarygtion(s)(Attaich boring rogs)
<br /> ProtecKon Rr�a ornat servfng a foocl, ❑ Two ptevious verific8tions(Attach bannglogs)
<br /> beve►age orlodging eshablishment:
<br /> �] Not applicabf�(MoJding tank(s),no dretnRefd)
<br /> brainReld hes at lesst a iwa�foot verilcal [J Unabl�to ver{ty(Saa Gammanta/�xp/anaNat)
<br /> separation d�stanoe from periodlcally
<br /> saturated soil or bedrock. ❑ Other(See CommB»ts�cpranation)
<br /> Non-perfarmance systems buJlt Apri11, �Yes C]Na CommentslF,xplanation:
<br /> 1996,0�Iat9r pr fOr non-pe►fprtnenGe ��,,�� �5�p
<br /> systems located in Shan�land or WeUhead
<br /> Profectian AreaB pr serving a fpod, T�-1����}_
<br /> beverage,orlodgingestebllshment:
<br /> Drainfield has a three-foot vettical
<br /> separation disiance from perfodlcalfy
<br /> saturated soil or bedrock."
<br /> °Eycper�mental", "Othe�', ar "Perfo»nance" � p Yes ❑No Indicate de ths oT elevgtions
<br /> sysrems durit underpre-2ooa Rures;rype iv � r ��a��,�:,:�'s�.��
<br /> ar V systems buAt under 2008 Rules(7080. A, eottom af distnbutlon media s,,fi,"4 0. ,� .,,��s a�.•s;,
<br /> 2350 or 7080.2a00 (Advgnced Inspector 5�,+�, . a,��
<br /> 1.Icense requl�d) B. Periodicell sakuratet!solUbedrocic ��,+a - �..G,
<br /> Drafnfield meets the designed vertical ��' 1 q�3 a.�e �
<br /> separation di�tanc�from periodiC�ily C. S stem se aration v a+ a,,
<br /> seturated soil ot bedroCk. .,y�, m�r��wo4�-4
<br /> D. R ulred cam IianCe se aration' 3•� ���X�)r.�,a�,�
<br /> Any"no"�nswer above indlca!`es the system is� "May be reduced up to 15 percant it allawed by Locef
<br /> Falling to_Protect Qroundwat�r. � ordinance. �
<br /> 5, pperat9nq Permit and N9trogen �Ahp*--Cbmpl�ance camponent#5 of 5 � Nat applicabie
<br /> Is the sy�tem oparated under an Operabng Pemrit? ❑Yes ❑No If"yea",A below Is requfred
<br /> Is the systerrl required to employ e Nitrogen BMP? ❑Yes []No ff"yea'",�beiouV Is required
<br /> BM�B�sf Menayement Precffce(s)apecih'ed ln the systenl design
<br /> If the answ�er to both quesflona!s"no';thls sectlon da�s not need to be comp/eted,
<br /> Com Ilance crlterta
<br /> a. Operating Permit number: �
<br /> Wave lhe Q erat�n Permft re ul�emeMt been metl �Y�g �NO
<br /> b. Is the re uired nitro en 8MP in 18Ce and ra erl functionin ? Yes No
<br /> Any"no"answerindicates Noncomp/lance.
<br /> Upg rAde ReqUlf�iments(MJnn.Stat.§115.55)M lmmin�nt thnaat ta pu6rl�¢ealth and safefy(fTRNS)must be upgraded,replaced,or its use
<br /> dlsaon!lnued wlthln ten months ofrecelp!of thls nofhae or wlthln$shp,ter pelfod if reqWred by IoCa!errlfnance.If the sysiem!s(alling fo profect
<br /> ground wafer,the system musf be up9+aded,rBplaced,orlts use dlscatNrlu9d wiFhin ttre f7me raqulred by fxal orClinence.K en e,rlsting system
<br /> is rnn falling as dellned in lew,erxi has et►east Iwa feet of deslyn aol!sep�raflon,thBn thg syst9m rreed'not be apgr�ded,r�peired,rBpleced,or
<br /> !ta use dlsca►tlnued,nohNPthsfending sny loce!orclln8n(ag fhat Is more sbict.fi!s p�oWslon 4ogs not�ppty ro systems In���Ra ereas,
<br /> wellhead PrvtecNon Arees,or those ased In canneclion with food peire�age,and lodgn,g eslabAshmenis ea deffnep;n lew.
<br /> www.pca,state.mn.us • 651-296-6300 • 800•b57•38b4 � TTY b5]•282-5332 or 80�657-38b4 • Available ir�altemative formats
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