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CProperty address: 1i4 j �V 6 �j� Inspector initials/Date: ! 4. Soil Separation— Compliance component#4 of 5 Date of installation: ❑Unknown Verification method(s): ShorelandMellhead protection/Food Beverage El No Lodging? Soil observation does not expire. Previous soil observations by two independent partes are sufficient, Compliance criteria: unless site conditions have been altered or local For systems built prior to April 1, 1996, and Yes ❑No requirements differ. not located in Shoreland or Wellhead ; Conducted soil observation(s)(Attach boring logs) Protection Area or not serving a food, ❑ Two previous verifications(Attach boring logs) beverage or lodging establishment ❑ Not applicable(Holding tank(s),no drainfield) Drainfield has at least a two-foot vertical ❑ Unable to verify(See CommentsrExplanation) separation distance from periodically saturated soil or bedrock. ❑ Other(See Commentst&planation) Non-performance systems built April 1, ❑Yes ❑No Comments/Explanation: 1996, or later or for non performance ,c 1 ` systems located in Shoreland or Wellhead / m� a c l /.4t •©.4 Protection Areas or serving a food, beverage, or lodging establishment: VkW w K� C6 Drainfield has athree-foot vertical ©� separation distance from periodically O saturated soil or bedrock.* Experimental, "Other', or `Performance" [:]Yes ❑No Indicate depths of elevations systems built under pre-2008 Rules; Type IV or V systems built under 2008 Rules(7080. A. Bottom of distribution media /OA 2350 or 7080.2400 (Advanced Inspector p License required) B. Periodicall saturated soil/bedrock [� S Drainfield meets the designed vertical C. S stem separation 6 k separation distance from periodically saturated soil or bedrock. 36 sr D. Required core liance separation* 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 X No If"yes",A below is required Is the system required to employ a Nitrogen BMP? ❑Yes UY 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: Have the Operating Permit re uirements been met? ❑Yes ❑No b. Is the required nitrogen BMP in place and properly functioning? ❑Yes ❑No Any "no"answer indicates Noncompliance. Upgrade Requirements(Minn. Stat.§115.55)An imminent threat to public health and safety(ITPHS)must be upgraded,replaced,or its use discontinued within ten months of receipt of this notice or within a shorter period if required by local ordinance.If the system is failing to protect ground water, the system must be upgraded,replaced,or its use discontinued within the time required by local ordinance.If an existing system is not failing as defined in law,and has at least two feet of design soil separation, then the system need not be upgraded,repaired,replaced,or its use discontinued,notwithstanding any local ordinance that is more strict. This provision does not apply to systems in shoreland areas, Wellhead Protection Areas,or those used in connection with food,beverage,and lodging establishments as defined 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-wwists4-31 • 1124112 Page 3 of 3