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Property address: '31)j2 o W)A zolvzi inspector initials/Date: y-7 <br /> 4. Solt Separation—Compliarioe component#4 of 5 <br /> Date of installation: O ONA ❑Unknown VeMflcadon method(s): <br /> ShorelandAAretthsed prootecBoNFoo d Bevewge ❑Yes ®No Soil observation does not expire.Previous sof! <br /> Lodging? 0bWM#W by two Independent parkas are sufhdentt, <br /> Compliance criteria: unless erre condllons have been altered or local <br /> For systems built pdfor to April 1, 996,and [j Yes ❑No requirements dam' <br /> not located In Shoreland or Well Conducted ad[observations}(Attach bodng roes) <br /> Prohechion Area or not servhrg a ❑ Two previous verlflcationsjo <br /> beverage or lodging establfs t: ( �ung ) <br /> ❑ <br /> DraintleW has at beast a twofoot vertical Not applicable(fang to"),no drafnfiefd) <br /> separation distance from periodically ❑ Unabld to verify(sae CommentsExp/anatron) <br /> saturated soil or bedrock. Cl Other(See Coaurentsl&rptena6a►) <br /> Non-peftmance systems bdItA.19 1, ®Yes []No Commentsll xplanafim: <br /> 1996,orlater orfor <br /> systems located In Sor ifhead <br /> Pmtecifon Areas or serving a food, <br /> beverage,or Wong establishment: <br /> Drainfleld has a three-foot vertical <br /> separation distance*om periodically <br /> saturated soil or bedrock.' <br /> Txpedmenter, •Other",or Teff0mance ❑Yes ❑No Indicate dapffis of elevations <br /> systems built underpre-2006 Ru s,Type 1V <br /> s • na. a;t sr�9 <br /> or V systems built under 2008 Rues(7080) A. Bottom of distftutian media yv,i -.�nZ, 1, ► ,� <br /> 2350 or 7080.2400 (Advanced Inspector <br /> License required) I B. Perbd aatiaated aolrodc 5e,.i+I;j A,3 ! <br /> Dralrtield meets the designed vertical separation ,r : , ,3 #'i�, <br /> separation distance from periodically <br /> saturated soli or bedrock. D. ulted our note ration« .3.0 <br /> Any"Ito"answer above 1 ill eatAs th8 system is Way be reduced up to 16 percent if allowed by Local <br /> Failing to Protect Groundwater_, Ordinance. <br /> 5. Operating Permit and Nitrogen BMP*—Compliance component#5 of 5 Not appiicable <br /> Is the system operated under an Operating Permit? ❑Yes ❑No it"yes",A below is required <br /> Is the system required to employ al Nitrogen BMP?- ❑Yes ❑No If"yes",B beto w.ts required <br /> BMP-Best Management PracOLWs)47salled M the sysism design <br /> ff the answer to both quesdoos is"no".this seedon does not need to be completed. <br /> Compliance criteria <br /> a. Operating Permit number. <br /> Yss [:]No <br /> Have the Operating Permit h m <br /> uireents been met? <br /> b. Is the required nitrom BMP!in ploy and functioning? Yes Q No <br /> Any"no"answer lndtcatlea Noncompliance, <br /> Upgrade Requilremeurts(MM.Stat'§I ia55)An k W*W threat to public breeM and SdW(>TRHS)must be upgiadad,replaced,or pis use <br /> clscaslnued w>6rin tan monBrS of f ft noft or wfti a Mw*peribd ffrequW by Wal art3he m.ff the system is&Wng to protect <br /> ground water,the system must be . ,re~orris use deconftW wlrhtn the tkne requksd by brit or dance!ran existing system <br /> is not faiffng as defined M law,and ho at least Me beet of destn,soli sapanift fhen the System need not be ypgraded repaired,replaced,or <br /> /ts use dls=drrrmd,notw/thsta *W OW imm ordhWM OW is mora Aft lids provlslon does not eA*to sysliam In sh""nd arras <br /> MMead Photection Amsa or those uod M eannedfon wfrb food beverage,and ibdt esablfshments as def nd M taw. <br /> Wffll-Wit,Stiltt,tlt US • 651.296.6311 • BM457.3564 TTY 651.2 5332 or B)W-394 Available in attamative formats <br /> wq-ww1sts4.31 1124112 <br />