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Property address: 88? 24, � A.0 Q <br /> Inspector initials/Date: <br /> 4. Soil Separation- Compliance component#4 of 5 <br /> Date of installation: <br /> Shoreland/Wellhead protection/Food Beverage ❑Unknown Verification method(s): <br /> Lodging? ❑Yes 12-No Soil observation does not expire. Previous soil <br /> Compliance criteria observations by two independent patties are sufficient, <br /> unless site conditions have been altered or local <br /> For systems built prior to April 1, 1996, and M requirements differ. <br /> not located in Shoreland or Wellhead � Yes ❑No ,.,/ <br /> nducted soil observation(s) (Attach boring logs) <br /> Protection Area or not serving a food, !� co <br /> 0 Two previous verifications(Attach boring logs) <br /> beverage or lodging establishment: <br /> 0 Not applicable(Holding tank(s),no grainfield) <br /> Drainfield has at least a two foot vertical <br /> 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, <br /> 1996, or later or for non-performance <br /> ❑Yes No Comments/Explanation. <br /> systems located in Shoreland or Wellhead `` <br /> Protection Areas or serving a food, �Ot v`��/L �'' /0r..... <br /> beverage, or lodging establishment: 4 J <br /> Drainfield has a three-foot vertical <br /> separation distance from periodically <br /> saturated soil or bedrock.* <br /> "Experimental'; "Other'; or `Performance" <br /> 0 Yes 21/No Indicate depths of elevations <br /> systems built under pre-2008 Rules; Type IV <br /> or V systems built under 2008 Rules(7080. <br /> 2350 or 7080.2400 (Advanced Inspector A. Bottom of distribution media �f '' <br /> License required) <br /> Drainfield meets the designed A+r B. Perind!caI!y saturated so!!;t;adrek /6 " <br /> separation distance from periodically <br /> C. S: : :ce <br /> saturatedsoildrkAny "no"answer above indicates the sysfem is DRseparation' r?� <br /> *May be reduced up to 15 percent if allowed by Local <br /> Failin• to Protect Groundwater. <br /> Ordinance. <br /> 5. Operating Permit and Nitrogen BMP*-Compliance component#5 of 5 ►' Not applicable <br /> Is the system operated under an Operating Permit? <br /> ❑Yes ❑No If"yes",A below is required <br /> Is the system required to employ a Nitrogen BMP? <br /> ❑Yes ❑No If"yes", B below is required <br /> BMP=Best Management Practice(s)specified in the system design <br /> If the answer to both questions is "no", this section does not need to be completed. <br /> Com•liance criteria <br /> a. Operating Permit number: <br /> Have the O•eratin• Permit re•uirements been ❑Yes 0 No <br /> b. Is the re•uired nitrogen BMP in 'lace and .ro•erl functioning? <br /> 0 Yes 0 No <br /> Any "no"answer indicates Noncompliance. <br /> Upgrade Requirements (Minn. Stat. §115.55)An imminent threat to public health and safety(ITPHS)must be upgraded,replaced,or its use <br /> 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 <br /> ground water, the system must be upgraded,replaced, or its use discontinued within the time required by local ordinance.If an existing system <br /> 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 <br /> its use discontinued,notwithstanding any local ordinance that is more 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 /> vww.pca.state.mn.us • 651-296-6300 0 800-657-3864 <br /> • <br /> rq-wwists4-31 • 1/24/12 TTY 651-282-5332 or 800-657-3864 . Available in alternative formats <br />