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Property address: Lig Inspector Initials!Date:' %2c'S*j <br /> 4. Soil Separation—Compliance component#4 of 5 <br /> Date of installation: °) r' 0 Unknown • Verification method(s): <br /> Shoreland/Wellhead protection/Food Beverage ❑yes No Soil observation does not expire.Previous soil <br /> Lodging? observations by two independent parties are sufficient, <br /> Com•Hance criteria: unless site conditions have been altered or local <br /> For systems built prior to Apr11 1, 1996,and ®Yes 0 No requirements differ. <br /> not located in Shoreland or Wellhead MI Conducted soil observations)(Attach boring logs) <br /> Protection Area or not serving a food, 0 Two previous verifications(Attach boring logs) <br /> beverage or lodging establishment: <br /> ❑ Not applicable(Holding tank(s),no dretnfieid) <br /> Drainfleld has at least a two-foot vertical 0 Unable to verify(See Comments/Explanation) <br /> separation distance from periodically <br /> saturated soil or bedrock. ❑ Other(See Comments/Explanation) <br /> Non-performance systems built April 1, ❑Yes 0 No Comments/Explanation: <br /> 1996,or later or for nonperformance <br /> systems located In Shoreland or Wellhead <br /> Protection Areas or serving a food, <br /> beverage,or lodging establishment: • <br /> Drainfleld has a three-foot vertical <br /> separation distance from periodically • <br /> saturated soil or bedrock.* <br /> "Experimenter,"Other,or Performance" ❑Yes 0 No Indicate de•the of elevations <br /> systems built under pre-2008 Rules;Type IV s< 5 :9 • tJ y#r p <br /> or V systems built under 2008 Rules(7080. A. Bottom of distribbution media <br /> 2350 or 7080.2400 (Advanced Inspector gt3+;1• i•fr <br /> License required) B. Perlodicall saturated salt/bedrock S'e'a I.0 <br /> Dralnfield meets the designed vertical so 1- 'S a.1., <br /> separation distance from periodically C. S - = se elation r. a• a•9 <br /> saturated soil or bedrock. D. R:.uired cam.iiance se.station' <br /> a-D/ <br /> Any"no"answer above indicates the system is- "May be reduced up to 15 percent if allowed by Local <br /> Falling to Protect Groundwater. Ordinance. <br /> )afrrr� -(o w+'4( 4 3.0 SOP rt4vr.S <br /> Avv,4x. w am>�v. <br /> 5. Operating Permit and Nitrogen BMP*—Compliance component#5 of 5 ®Not applicable <br /> Is the system operated under an Operating Permit? ❑Yes 0 No If"yes",A below Is required <br /> Is the system required to employ a Nitrogen BMP? ❑Yes 0 No If"yes",B below la 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 /> Compliance criteria <br /> a. Operating Permit number. <br /> Have the Operating Permit requirements been met? ❑Yes ❑No <br /> b. is the required nitrogen BMP in place and properly functioning? ❑Yes 0 No <br /> Any"no"answer indicates Noncompliance, <br /> • <br /> Upgrade Requirements(Minn.Stat.§115.56)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 felling 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 /> m,Q6dStatie,ifli s 651.196.6306 • 800.657.3864 • TTY 651482.5332 or 960657.3864 • Available in alternative ionnats <br /> wq-wwists4-31 • 1/24/12 <br />