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Property address: Al,�010 q �,��, .{�y�Inspector initial8IDate; ;��" IQ --e—,70 <br />(mmlddlyyyy) <br />4. Soil Separation —Compliance component #4 of 5 <br />Date Of installation: app oZ ❑ Unknown Verification method(s): <br />(mmlddlyyyy) <br />ShorelandNVei(head protectiontFood beverage Soil observation does not expire, Previous soil <br />lodging? Q Yes [B No observations by two independent parties are sufficient, <br />unless site Conditions have been altered orlocal <br />Compliance criteria: requirements differ. <br />For systems built prior to April 1, 1996, and Q Yes (] No <br />not located in Shoretand or Wellhead <br />Protection Area or not serving a food, <br />beverage or lodging establishment: <br />Drainfield has at least a two -foot vertical <br />separation distance from periodically <br />Non-periormance systems built April 1. ® Yes Q No <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 ❑ No <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 <br />License required) <br />Drainfield meets the designed vertical <br />separation distance from periodically <br />saturated soil or bedrock. <br />Any "no" answer above indicates the system is <br />failing to protect groundwater. <br />M Conducted soil observation(s) (Attach boring logs) <br />Q Two previous verifications (Attach boring logs) <br />Q Not applicable (Holding tank(s), no drainfield) <br />Q Unable to verify (See Comments/Explanation) <br />Q Other (See commentsiExplanation) <br />Comments/Explanation: <br />Indicate depths or elevations <br />A. Bottom of distribution media S. tis 'a • q, a a,a " <br />5'si�_ , <br />B. Periodical!y saturated soil/bedrock s z l a - <br />5'i3ti 1- ,q <br />C• System separation yV, f A . g,7' <br />D. Required compliance separation" -�' o i <br />"May be reduced up to 15 percent if allowed by Local <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? Q Yes ❑ No If "yes", A below is required <br />Is the systam required to employ a Nitrogen BMP? Q Yes Q 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 />Have the Operating Permit requirements been met? ❑ Yes Q 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. Stal. 9 1 i5.53) An imminent threat to public health and safety (!TANS) must be upgraded, replaced, orits 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 few, and has at least two teat 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,state.mn.us • 651-296-6300 800-657-3864 TTY 651-282-5332 or 800-657.3864 • Available in alternative formats <br />wq-wwists4-3 ib • 614114 <br />