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. . <br /> . <br /> ' PropBrtyadaress: ' a;a•.°i.o �bv►.�w�or;� �wr!-� Inapedaru�fialsmate:'��:' —�t..��} <br /> 4. Soi l Seperation—Compfiance oamponent#4 of 5 <br /> Date ot Installatlon: 1 q��� ❑Unknawn ' Verlflc�don method(s): <br /> ShontamdlWeithead R�+�oNFaod 88`re+aee 'Q Yes �No So/l cbsetvaBan does rtot�xplie.Prevlous soA <br /> �OC�"� . obaenratlans 6y fwo btdependenf par6es aro su�fldent <br /> Co llance ctlterla: wrless si�can�ffons heve been altered oNocat <br /> lrwrsysCems bufR pdorfo A{�n71,1996,end ❑Ya ■No ��mettts tdH'er. <br /> not lt�catedJn Shoreler�d aWeUheed ■ Condt�ted aon observattan{s)(Attach trwi�►glopa) <br /> ProfecXon Area arirof aetvbig a food L7 Twa previovs ve�iica6a�s(AtteaF+bodr�1ogsl <br /> bevarage or fodgiUt�esla69siun8rt� ❑ No1 app3lcable(Hclding im►h(s),no dret,�ta�ry <br /> Drah�flald hss at least a twafoot vert�ai 0 Uneblei to vedfy(see f�ommenta/Explenadon) <br /> seperaBon dtstarme frcm pedodlcaUy � � Other(Sae Commerasr6cp►a,iattonl <br /> saturated sd1 or bedrodc. • <br /> Nort�pedom»ara:a systema brd�t AprB i, �Yes ❑No Conunenfs/Expla»atfoa; <br /> 1896,oNaterortotaon-performera:e ' <br /> systemsfoc�stedlnS`harelandorWe9head • . <br /> Prorecflar+Areas orserving a tooat, . <br /> bevsmge,erlodging esfebqshmenh . . <br /> DrelnAeld has a three-foot vetttcai <br /> sepa�etlon distance 5�om pedcdicalty � ' <br /> saturatad aoll or bedrock.' <br /> �irperlmerdal;°Othe�',ar'Ae�famenr.e'� . ❑Yes ❑No lndlCats depths Of etevatloris <br /> sy�ems baUt under pre-2008 Rules;Type N' gqy r • . . . . <br /> orV systems bultt ur►der2008 Ru/es(7080. A. Boflan of iiiatrmution me�a � ►.,�•. • <br /> 2350or7Q80.240D {/ldvancsdlnepec�or • g��.� �,�� <br /> ucense reqUirs� . e. Pedodioal►r eat�uafea soBlbearodc s sa•� a,a• <br /> �t�tnfleld meeta the desig�8d verUCeS C. � t�n ae n &5��� •'3�• .. <br /> seperaUon distanoe trom perfodica�y . <br /> satu[ated eoii a'bedrock. �,c� <br /> 0. oom M <br /> Any"no"answer above Ittdlcates the system Is• *�y be reduced up to 16 peccettt If ellowed.6y Lccal <br /> Falfing to Protecf Grormdwater. p��, <br /> 5. Operat9ng Permit and N9tragen BMP*—C'orn�iance compone�t�s of 6 �Not appticab[e <br /> .Is tha syetem operaied nnder an Operatfig Aertnit? O Yes ❑No If"yss".A balaa►is requirad . <br /> le the system required to empioy a f�tlVogen BMP?• C1 Yes Q No (t"yes°.B betoxt ts reqatred <br /> B119PaBest Meiragemerft Prnr�lae(sj apedfisd in!he sys[em daaJgn <br /> N the answ►�to bath quesflons Is"no;thls sscfiorr daes nof�laed to be completed. <br /> Com Ifartce cei�erla <br /> a. OperaB�Pem�ii number: � <br /> Have the 0 ' �Pem►it v)remantc been m�t? ❑Yes ❑No <br /> b. Is the red n en BMP�n Iace a� ' Yes No <br /> My uno"anawer Indlcates Noncompllarrce. � <br /> � Upgiade Requiremen�(Mfnn.Stet§1JB.6�M�nt 9ueat fi pub�(teeRf►and selety(iTP.HS}must 6e apgreded,ropt�ed,orlts use <br /> tQscvnHnued avRhltl ten monfhsofrecs4��Utls nOfk�aw1U►5r B shvberperfodUreqteGsdby(ocaf ortBnence.BUae eystem isfal�ng ttlprofect <br /> gmund water,!ha sYstem muffibe 1�9►8de�rsptsaeri,arfls usq dlsoontlnr�ed�fha Ome rs4utrod by lo�o�i+er►ee.ffan e�ttngaystem <br /> la na#fa�nq a4 def/ned7n Jan,and hes�feeat hqo teet addesk�rr eaAsepe►afforti O�en U�e 8qatem rreednnt 6e ap�aded,rapabed,te�aoed,ar <br /> !ts ttse�nneQ n�wi�sbandlrtp anY��9rat7smare aC�L 7ltis Pravl�on daesnot apply(o st�ems/n�o�eland ereas. <br /> Wel�e6d Protecflon A►ee�arthose irsed6l oormeodon wA'h faod.beverape,eted�rp estabdshmanls as detGred In ta�v. <br /> www.pca.State.mn.u5 � 651•19b�63M0 • �-657 38�4 � 1T!b5118t�32 cr 6oa65�•3s6a • A�n���►$t�we ta�,� <br /> wq-�►vrst�e-3� . t�a4n� ' • - <br />