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Oct. 31. 2013 12:03PM No. 2113 P. 7 <br /> Property address inspector initials/Date: <br /> 4. Soil Separation—Compliance component#4 of 5 <br /> Date of Installation: 1 -Q7..- 1c4 U Unknown Verification method(s): <br /> Shorelandtwaiihead protection/Food Beverage 0 Yes No Soil observation does not expire. Previous soil <br /> Lodging? observations by two independent parties are sufficient, <br /> Com•liance criteria: unless site conditions have been altered or local <br /> requirements differ. <br /> For systems built prior to April 1, 1996, and al Yes 0 No <br /> not located in Shoreland or Wellhead ® Conducted soil observations)(Attach boring logs) <br /> Protection Area or not serving a food, ❑ Two previous verifications(Attach boring logs) <br /> beverage or lodging establishment: <br /> ❑ Not applicable(Holding tank(s),no dralnflefd) <br /> grainfield has at least a two-foot vertical 0 Unable to verify(See Comments/Explanation) <br /> separation distance from periodically <br /> saturated soil or bedrock. El Other(Sea Commenfs/lJcpfanatfon) <br /> Non-performance systems built April 1, 0 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" ❑Yes 0 No Indicate de.the of elevations <br /> systems built under pre-2008 Rules;Type IV Z. <br /> or V systems built under 2008 Rules(7080. A. Bottom of distribution media .$12• .,g i 7•y • <br /> 2350 or 7080,2400 (Advanced Inspector scs• I .7 i.•s' <br /> License required) B. Periodical/ saturated solUbedrock S'si6• <br /> grainfield meets the designed vertical5 N,d _ •4 '3re• <br /> j- <br /> separation distance from periodically C. 5 stem se•araticn <br /> saturated soil or bedrock. D. Required compliance separation' 1 ' 0 <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? ❑Yes © 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 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 /> ❑Yes ❑No <br /> Have the Operating Permit requirements been met? - - <br /> b. Is the required nitrogen BMP in place and properly functioning? ❑Yes 0 No <br /> Any"no"answer indicates Noncompliance. <br /> Upgrade Requirements(Minn.Stat.§115.55)An imminent threat to public health and safety(ITPNS)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 falling 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 /> www.pca.5tate.mn.us • 651-296-6300 • . 800.657-3864 • TTY 651-282-5332 or 300-657.3864 . Available in alternative formats <br /> wq-wwists4-31 • 11.24/12 <br />