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Page 3 of 3 <br />Property address: Inspector initials/Date: | <br />(mm/dd/yyyy) <br />4.Soil Separation – Compliance component #4 of 5 <br />Date of installation: Unknown Verification method(s): <br />Soil observation does not expire. Previous soil <br />observations by two independent parties are sufficient, <br />unless site conditions have been altered or local <br />requirements differ. <br /> Conducted soil observation(s) (Attach boring logs) <br /> Two previous verifications (Attach boring logs) <br /> Not applicable (Holding tank(s), no drainfield) <br /> Unable to verify (See Comments/Explanation) <br /> Other (See Comments/Explanation) <br />(mm/dd/yyyy) <br />Shoreland/Wellhead protection/Food beverage <br />lodging? Yes No <br />Compliance criteria: <br />For systems built prior to April 1, 1996, and <br />not located in Shoreland 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 />saturated soil or bedrock. <br /> Yes No <br />Non-performance systems built April 1, <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 />Yes No Comments/Explanation: <br />“Experimental”, “Other”, or “Performance” <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 /> Yes No <br />A.Bottom of distribution media <br />B.Periodically saturated soil/bedrock <br />C.System separation <br />D.Required compliance separation* <br />Any “no” answer above indicates the system is <br />failing to protect groundwater. <br /> <br />5.Operating Permit and Nitrogen BMP* – Compliance component #5 of 5 Not applicable <br /> Yes No If “yes”, A below is required <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 />Compliance criteria <br /> Yes No Have the Operating Permit requirements been met? <br />b.Is the required nitrogen BMP in place and properly functioning? Yes 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. If the system is failing to protect ground water, the system must be upgraded, replaced, <br />or its use discontinued within three years of receipt of this notice. If an existing system is not failing as defined in law, and has at least two feet <br />of design soil separation, then the system need not be upgraded, repaired, replaced, or its use discontinued. This provision does not apply to <br />systems in shoreland areas, Wellhead Protection Areas, or those used in connection with food, beverage, and lodging establishments as <br />defined in law. <br />160 Big Island 10/06/2020 <br />10/06/2020 <br />X <br />952.7 <br />949.7 <br />3 <br />X <br />Benchmark 949.4 assumed at corner pin for lot <br /> Indicate depths or elevations <br />Is the system operated under an Operating Permit? <br />Is the system required to employ a Nitrogen BMP? <br />a.Operating Permit number: <br />3 <br />RLP <br />X