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01/22/2015 13:35 9528733112 PAGE 03/04 i Property address: 4765 Watertown Road-Orono Inspector initialvDate: JS 1 1/22/2015 (mm/dd,~ 4. Soil Separation—Compliance component#4 of 5 Daft of installation: 5/3/19s8 ❑Unknown Verification method(s); (mmkid/yyyy) Shoreland/Wellhead protectknuftod beverage Soil observation does not expire. Previous sot! lodging? ®Yes ❑No observations by two independent parties aro sufficient, unless site conditions have been altered or local Compliance criteria: requirements differ For systems built prior to April i, 1996,and ❑Yes ❑No ®Conducted soil observation(s)(Attach boring logs) not located in Shore/and or Wellhead Two previous vett Protection Area or not serving a food, verifications(Attach boring kgs) beverage or lodging establishment: ❑ Not applicable(Ndding tank(s),no draln6etd) Drainfleld has at least a two-foot vertical Unable to verify(See Commenw&phrwtion) separation distance from periodically ❑Other(See CommentsIftbriation) saturated soil or bedrock. Nonperformance systems built April 1, ®Yes ❑ No Cottlment&Txplanatlon• 1996,or later or for non-performance systems located in Shoreland or Wellhead Boring: Protection Areas or serving a food, 1-18"10YR 2/2 Loam beverage, or lodging establishment 18-26" 10YR 4/4 Clay Loam Drainfleld has a three-foot vertical Separation distance from periodically Motts 0 21' saturated soil or bedrock.' Experimental", "Other", or 'Performance" ❑Yes ❑No Indicate depths or elevations systems built under pre-2008 Rules.Type 1V or V systems built under 2008 Rules(7080. A. Bottom of distribution media 16'plus or more 2350 or 7080.2400 (Advanced Inspector License required) B. Perlodical saturated soillbedrock 21' Drainfleld meets the designed vertical C. System Separation 36"plus separation distance from periodically saturated soil or bedrock, D. R uired cam lance se ration" 36" Any"no"answer above indicates the system is *May be reduced up to 15 percent if allowed by Local fabling to protect groundwater, ordinance. S. Operating Permit and Nitrogen BMP*—Compliance component#5 of 5 ® Not applicable Is the system operated under an Operating Permit? ❑Yes ❑No It"yes",A below is required Is the system required to employ a Nitrogen BMP? ❑Yes ❑No If"yeas",B below is required BMP a Best Management Practics(s)spaded in the system design N the answer to both questions is "no", this section does not need to be completed. Compliance criteria a. Operating Permit number. ❑Yes [I No Have the Operating Permit requirements been met? b. Is the required nitrogen BMP in placa,and properly functioning? Yes El No Any"no"answer indicates Noncompliance. Upgrade Requirements(Minn.Star.f 115.55)An imminent throat to public hearth and safety(trPHS)must be upgraded,replaced,or ft use discontinued within tan monft of receipt of this nolfce or within a shorter period ff required by local ordinance,if the system is fa ft to protect ground water,the system must be upgraded,replaced,or its use discontinued within the time required by focal ordinance,If an existing system is not fafling as defined In taw,and has at least two feet of design soil separation,then the system need not be upgraded.repaired,replaced,or its use dsconflnued,notwti'tfrs>and ng any local ordinance that is more strict This provision does not apply to systems in shor aland areas, Wellhead Protection Areas,or Owe used in owfmclion with food,beverage,and lodging egt8bfishments 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-wwists4-3 t • 3116112 pme 3 of 3