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Property Address: <br />Business Name: <br />S. Soil separation — Compliance component 45 of 5 <br />Date of installation Q- 1�14 - ;�O ❑ Unknown <br />(mm/dd/yyyy) <br />Shoreland/Wellhead protectionlFood ❑ Yes ❑ No <br />beverage lodging? <br />Compliance criteria (select one): <br />5a. For systems built prior to April 1, 1996, and ❑ Yes ❑ No* <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 />5b.Non performance systems built ® Yes ❑ No" <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" ❑ Yes ❑ No* <br />systems built under pre -2008 Rules,- <br />Type <br />ules;Type IV or V systems built under 2008 <br />Rules 7080. 2350 or 7080.2400 <br />(Intermediate Inspector License required <_ <br />2,500 gallons per day; Advanced Inspector <br />License required > 2,500 gallons per day) <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 />Describe verification methods and results: <br />Date: -3 -TS�- ;� ;� <br />Attached supporting documentation: <br />❑ Soil observation logs completed for the report <br />® Two previous verifications of required vertical separation <br />❑ Not applicable (No soil treatment area) <br />0r0�,sC7 M �--' 501� <br />009 a,4 . - 1 a " <br />ox,�, <br />Indicate depths or elevations <br />1511411 - ) a a <br />A. Bottom of distribution media 5,o -A !o :z <br />4r <br />B. Periodical) saturated soil/bedrock 1 a <br />- <br />C. System separation z"r 1 3 .c <br />SVIR -3- <br />D. <br />,D. Required compliance separation* z,f31 <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, orits 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, or its 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 />htips://www.pca.state.mn.us 651-296-6300 - 800-657-3864 Use your preferred relay service Available in alternative formats <br />wq-wwists4-31b • 4/28/2021 Page 4 of 4 <br />Q S"47 <br />