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Fro e rty address: O , 'f, pInspectorinitials/ate: / ., G at3 <br />4. Soil SepdrBtion—Compliance component#4 of 5 <br />Date of instaliation: Unknown <br />Shoreland/Wellhead protection/Food Bevere e <br />Verification method(s): <br />Lodging? g Yes o Soi/observa6on does not expire. P vious soil <br />Com liance criteria: obseivations by two independent partres are s cient, <br />un/ess site conditions have been alter d or localForsystemsbuiltpriortoApril9, 19g6, and Yes No 9uirements difier. <br />not located in Shor land or Wel/head I Conducted soil observation(s)(Attach boring logs)Protecfion A a or not senring a food,beverage orlodging establishment.• Two previous verifications(Attach boring logs) <br />Drainfield has at least a two-foot vertical Not applicable(Holding tank(s);no drainfield) <br />separation distance from periodically Unable to verify(See CommentsiExplanation) <br />saturated soil or bedrock. Other(See Comments Explanation) <br />Nonperf nnance systems built April 1, Yes1996, or later o for nonpertormance <br />No Comments/Explanation.• <br />C <br />systems/ocated in Shore/and or Wellhead a ,pA,Protection Areas or serving a food, <br />beverage, orlodging establishment. <br />t, <br />K S" 4 , <br />0,. <br />Drainfield has a three-foot vertical <br />n <br />separation distance from periodically fQ,£,Dsaturatedsoilorbedrock.* <br />Experimental'; "Other; or Pertormance" Yes Nosystemsbuiltundepre-2008 Rules; Type 1V Indicate de ths of elevations <br />or V systems built under 2008 Rules(7080. A. Bottom of distribution media K2350or7080.2400 (Advanced Inspector <br />License required) <br />u <br />Drainfield meets the designed vertical <br />B• Periodicall saturated soil/bedrock <br />separation distance from periodically C. S stem se aration 38 <br />saturated soil or bedrock. <br />D. Re uired com liance se aration'Any "no"answer above i dicates the system isFailingtoProtectGroundwater. May be reduced up to 15 percent if allowed by LocalOrdinance. <br />5. Operating Permit and Nitrogen BMP*—comp iance com onent#s of s Not applicable <br />Is the system operated under an Operating Permit? Yes o If yes ,A below is requiredIsthesystemrequiredtoemployaNitrogenBMP? Yes 10 If"yes", B below is required <br />BMP=Best Management Practice(s)specified in the system design <br />lf the answer to both questions is "no'; this section does not need to be completed. <br />Com liance criteria <br />a. Operating Permit number: <br />Have the O eratin Permit re uirements been met? <br />Yes No <br />b. Is the re uired nitro en BMP in lace and ro erl functionin ?Yes No <br />Any"no"answer indicates Noncompliance, <br />Upgrade Requirements(Minn. Stat.§115.55)An imminent thieat to public health and safety(ITPHS)must be upgraded,replace.d,or its usediscontinuedwithintenmonthsofreceiptofthisnoticeorwithinashorterperiodifrequiredbylocalordinance.If the system is failing to protectgroundwater, the system must be upgraded,replaced, or its use discontinued within the time required by local ordinance.If an existing systemisnotfailingasdefinedinlaw, and has at least Iwo feet of design soil separation, then the system need not be upgraded,repa)r d,rep aced,oritsusediscontinued,nolwithstanding any/oca/ordinance that is more strict. This provision does not apply to systems in shoreland areas,Wellhead Protection Areas, or those used in connection with food,beverage,and lodging establishments as defrned 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 formatswq-wwists4-31 • 1/24/1.2 <br />Page 3 of 3