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Property Address: 3 ka <br />Business Name: , P <br />-�,A {.d Z 1A\\,\, <br />5. Soil separation — Compliance component #5 of 5 <br />Date of installation 4 r I Z - PrJ ElUnknown <br />(mm/ddlyyyy) <br />5horeiandNVelIhead protectionlFood <br />beverage lodging? <br />Compliance criteria select one <br />5a. 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-fopt vertical <br />separation distance from periodically <br />saturated soil or bedrock. <br />5b.Non-performance systems built <br />April 1, 1996, or later or for non- <br />performance systems located in Shoreland <br />or Wellhead Protection Areas or serving a <br />food, beverage, orlodging establishment- <br />Drainfield has a three-foot vertical <br />separation distance from periodically <br />saturated soil or bedrock.* <br />5c. "Experimental", "Other", or "Performance" <br />systems built under pre-2008Rules; <br />Type IV or V systems built under 20018 <br />Rules 7080. 2350 or 7080.2400 <br />(intermediate Inspector License required <br />2,500 gallons per day; Advanced Inspector <br />License required 5 2,500 gallons per day) <br />Drainfield meets the designed vertical <br />separation distance from periodically <br />saturated soil or bedrock. <br />Date: - to -,a -0), <br />Yes ❑ No Attached supporting documentation: <br />❑ Soil observation logs completed for the report <br />0 Two previous verifications of required vertical separation <br />❑ Yes ❑ No" ❑ Not applicable (No soil treatment area) <br />vaz•-�' �t��i c�� v4.��,��1 <br />11 Yes ❑ No* Indicate depths or elevations <br />Yes ❑ No* <br />*Any "no" answer above indicates the system is <br />failing to protect groundwater. <br />Describe verification methods and results: <br />A. Bottom of distribution media <br />B. Periodically saturated soil/bedrock <br />C. System se ration <br />D. Required compliance separation* <br />is -3 •tor �' 3 • v + <br />3�o r <br />*May be reduced up to 15 percent if allowed by Local <br />Ordinance. <br />Upgrade requirements: (Minn. Stat. § 115.55) An imminent threat to public health and safety (ITPHS) must be upgraded, replaced, <br />or its use discontinued within ten months of receipt of this notice or within a shorter period if required by local ordinance. If the <br />system is failing to protect ground water, the system must be upgraded, replaced, or its use discontinued within the time required by <br />local ordinance. If an existing system is not failing as defined in law, and has at least two feet of design soil separation, then the <br />system need not be upgraded, repaired, replaced, orits use discontinued, notwithstanding any local ordinance that is more strict.. <br />This provision does not apply to systems in shoreland areas, Wellhead Protection Areas, or those used in connection with food, <br />beverage, and lodging establishments as defined in law. <br />https://www.pca.state.mn.us 651-296-6300 • 800-657-3864 Use your preferred relay service Available in alternative formats <br />wq-wwists4-31b • 4/2$/202.1 Page 4 of 4 <br />