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, Property address: 2,10D ,11' Inspector initials/Date: ` l��l l `•�-'�-19 <br /> 4. Soil Separation—Compliance component#4 of 5 <br /> Date of installation: `7 )"")cY ❑Unknown Verification method(s): <br /> ShoreandNVelihead protectioMFood Beverage ElYes ®No Soil observation does not expire. Previous soil <br /> Lodging? <br /> observations by two independent parties are sufficient, <br /> Compliance criteria: unless site conditions have been altered or local <br /> For systems built prior to April 1, 1996,and 0 Yes 0 No requirements difiSer. <br /> not located in Shoreland or Wellhead ® Conducted soil observation(s) (Attach boring logs) <br /> Protection Area or not serving a food, <br /> beverage or lodging establishment: ❑ Two previous verifications (Attach boring logs) <br /> ❑ Not applicable(Holding tank(s),no drainfield) <br /> Drainfield has at least a two-foot vertical 0 Unable to verify (See Comments/Explanation) <br /> separation distance from periodically <br /> saturated soil or bedrock. 0 Other(See Comments/Explanation) <br /> Non-performance systems built April 1, i Yes 0 No Comments/Explanation: <br /> 1996, or later or for non-performance <br /> systems located in Shoreland or Wellhead <br /> Protection Areas or serving a food, <br /> beverage, or lodging establishment: <br /> Drainfield has a three-foot vertical <br /> separation distance from periodically <br /> saturated soil or bedrock.* <br /> 'Experimental", `Other", or `Performance" 0 Yes 0 No indicate depths of elevations <br /> systems built under pre-2008 Rules; Type iif •s o <br /> or V systems built under 2008 Rules(7080. A. Bottom of distribution media v•-•\i > >'54-1.5- ---; <br /> 2350 or 7080.2400 (Advanced Inspector tw r I. a•s' <br /> License required) B. Periodically saturated soil/bedrock 'a A.3 <br /> Drainfield meets the designed vertical 5-6,414 v.o' <br /> separation distance from periodically C. System separation 5y. _s y3.11 <br /> saturated soil or bedrock. D. Required compliance separation' <br /> Any "no"answer above indicates the system Is- *May be reduced up to 15 percent if allowed by Local <br /> Failing to Protect Groundwater. Ordinance. <br /> 5. Operating Permit and Nitrogen BMP*-Compliance component#5 of 5 Not applicable <br /> . Is the system operated under an Operating Permit? 0 Yes 0 No If"yes",A below Is required <br /> Is the system required to employ a Nitrogen BMP?• 0 Yes 0 No If"yes", B below Is required <br /> BMP--Best Management Practices)specified in the system design <br /> if the answer to both questions is "no",this section does not need to be completed. <br /> Compliance criteria <br /> a. Operating Permit number: <br /> Have the Operating Permit requirements been met?Have © No <br /> b. Is the required nitrogen BMP in place and properly functioning? ❑Yes ❑ No <br /> Any"no"answer indicates Noncompliance, <br /> Upgrade Requirements(Minn. Stat.§116.55)An imminent threat to public health and safely(ITPHS)must be upgraded,replaced, or its use <br /> discontinued within tan months of receipt of this notice or within a shorterperiod if required by local ordinance.if the system is failing to protect <br /> ground water,the system must be upgraded,replaced,or its use discontinued within the time required by local ordinance. if en existing system <br /> Is not falling as defined in law,end has at least two feet of design soil separation,then the system need not be upgraded,repaired,replaced, or <br /> its use discontinued,notwithstanding any local ordinance that is mom strict This provision does not apply to systems in shoreland areas, <br /> Wellhead Protection Areas, or those used in connection with food,beverage,and lodging establishments as defined in law. <br /> w N4.pca.state.Clln.us • 651.296.6300 9 BOO 657.3B64 s TTY 651.2B2..5332 or BOO. 573864 0 Available in alternative formats <br />