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Property address: U1S b 0'4-�k Ui ''9¢.J� Inspector Initials/Date: 505- <br />4. Soil Separation— Compliance component #4 of 5 - <br />Date of installation: q a 3 p Unlmown <br />ahorelandlwellhead profectiomPood Beverage Yes No <br />Lodging? <br />rbrsystems bulltpdor io April1, 19ge, end <br />not located In Shoreland or Wellhead <br />Protection Area or not serving a food, <br />beverage orlodging establishment: <br />Drainfield has at least a tv o foot vertical <br />separation distance from periodically <br />Non-pedbirmunce systems builtApnY 1, <br />1996, orlaterorfornon-pedormance <br />systems located in Shoreland or Wellhead <br />Protection Areas orserving a food, <br />beverage, orlodging establishment: <br />Drainfield has a three-foot verticill <br />separation distance from periodically <br />Saturated soil or bedrock.• <br />❑ Yes ® No <br />❑ Yes ❑ No <br />'Experimental; "Other, or'Pedolmance' ❑ Yes ❑ No <br />systems built underprs-2008 Rules; Type IV <br />Or systems built under2008 Rules (7080. <br />2350 or 7080.2400 (Advanced Inspector <br />License required) <br />Dralnfeld meets the designed vertical <br />separation distance from periodically <br />saturated soil or bedrock. <br />Any "no" answer above indicates the ain am, Is <br />Verification mathod(e): <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 dilfet <br />M Conducted $oil Observation(s) (Attach boring logs) <br />❑ Two previous verifications (Attach boring logs) <br />❑ Not apps cable (Holding tank(s), no dralnaeid) <br />❑ Unabld to verify (See Comments/Exp/anellon) <br />❑ Other (See Commentse pienalion) <br />CommentslExplenation: <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 Permh? ❑Yes ❑ No If'yes", A below re required <br />Is the system required to employ a Nitrogen BMP? ❑ Yes ❑ No If 'Yes', a below Is required <br />BMP -Best ManagementPrectice(s) specf6ed 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 bean met? ❑ Yes ❑ No <br />b. Is the required nitrogen BMP in place and propedv functligim9? ❑Yes ❑ No <br />Any "no"answer Indicates Noncompliance, <br />ygIMI-P2SMUM-M r 651.296-M • BM -657.3664 . ttY651.M-5332or MD.657.3IM . Availab(ein alternative formats <br />