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� PropeAY addreas: �4 l�' �,h�'��,d� _ � Inapector initlaisNate:'.��i _�S-a��1� <br /> 4. Soi l Separatlon—Compliance component#4 oi 5 <br /> Date of instaliation: ��c7'S ❑Unkrrown ' Ver[fl tion method(a): <br /> shoralandANellhaad protacUoNFood 8eve�ye �Yes �No So11 o ervatlon Aoes not e�tplre.Previous soif <br /> LOdg{"87 obse dons by Mro Independent pafies are suHfcfent <br /> Com liance criteria: unle site c�nditions have been altered orlocal <br /> Forsystems built prfor fo Apd/f, 19b6,and ❑Yea ❑No �Qu! ments difl'er. <br /> not located in Shoreland orWel(head � nducted soil observatbn(s)(aaech aodr,�roDs) <br /> Protectlon Area or not serving a food, ❑ T prevfoua verHfcatlons(AKach borfirg logs) <br /> 6everage orladging esta6lishment: <br /> ❑ N applicable(Holdtng tank(s),no dral»11e1� <br /> Dreirrftaid has at least a two-foot vertical ❑ U abl�to verity(See Commenta/Fxplenallon) <br /> separetion distence from periodical3y <br /> satureted sofl or bedrock. ❑ er(See Comments/�cpianaHon) <br /> Non-perfortnance systems bulR Ap►i11, �Yes ❑No Co entsJEuplanafiwi: <br /> 1986,orlaterorfornon�erlormence <br /> systems located in Sho�eland orWeNhaed � <br /> ProtecHon Arees or servinq a food, <br /> beverege,oriodging establlahmenh . . � <br /> Drainfield has a three-foot vetticaE <br /> separstion distance from pBrlodfcafiy ' <br /> saturated soil or bedrodc` <br /> Expedmental;`OEher",or Performanca'� ❑Yes ❑No lndi te de hs of elevations <br /> systems buAt under pre-2008 Rufes;Tjpe IV g. .3'.�;q'sa,,,b <br /> or V systems bulit under 2008 Rules(7a80. A. B om ot dtst�utlon medio S�' �r. .5.�.'s yo� <br /> 2350 or 7080.2400 (Advanced Inspector • �p,r a, �,� . <br /> License requir9d) B. P icel sahuabd wlUbedrodc Sg✓a �-,3�. <br /> Drair�'iefd meeta the designed vertical �'�`3' �"�,;'� <br /> separation�stence irom periodicaUy C. '��0" 'a v • .� <br /> saturated soil or bedrock. ' <br /> D, utred cam Ilanoe se araBon• 3•O <br /> Al1y"rto"answer above Indlcates fhe sysfem Js� •Ma be raduoed up to 15 percent If allowed�by Locai <br /> FaJIing to Protect Groundwater. or ance. <br /> 5. Operating Permit and Nitrogen BMP*—Cbmplla�ce compo ent�15 of 5 �Not applicable <br /> Is the system operated under an Opereting Pertnit? [j Ye� 0 No I "yes",A befpw is required . <br /> Is the system required to employ a NRrogen BMA?� �Yea ❑No I "yaa",B below is raqulred <br /> BMI�Best Menagement Prectice(sJ specalled in the systsm deslpn <br /> if the answer fo bofh quesHons!s"no';this secifon.does nof n Lo be completed. <br /> . . � <br /> Com liance cdteNa . <br /> a. Operating Permk number. � <br /> Have the 0 eraUn Pertnit uirements been met? Yea ❑No <br /> b. Is the re uired ni en BMP in tace and ro rl funcdonin ? Yes No <br /> Any"no"answer In�cates Noncomp/lance. <br /> Upyrade Requiremants(Minn.Stat§115.55j M imminent fhreat lo puWfc�ealN d�afety(ITRHS)mustbe upgraded replaced,orlis use <br /> dlsconlLwed witbin ten monfhs of recefpt�thfs nof&:e or wlfhln e ahorterpertod M by lor.e!ard(nerece.if the aystem!s falqng to protect <br /> qround wafer,the systam muaf be�ppraded,rap/aced,or fts use dl,soontlnued wNh1n dme requGsd by 1oql adinaxe.d an euisNnp system <br /> is not talNnp an deRned In lew,and has at least hvo feet of d�e�gn aoll separeflart tl�en e aysDam need not 6e upgraded,�epalred,replaced,or <br /> Rs u�dfsconUnued,rroriWfhstandhig eny facef adlnance fhat fs more�trkt 7hLs doea notappy to syarema!n shoreland areas, <br /> WeUheed ProteoNon Areaa,w those uaed!n connecNon tWth k�od bet�repe,ard eata6llshments es deifned In law. <br /> W�YVI.QCa.S�2�.1i111,1lS � 6��•Z�� � ��651•3�4 � T[Y 651182-53 a'864�657•386t • kvallnbk in altematSve 4ormats <br /> wq-wwlsW-31 . 1/24/f2 � . <br /> ;i <br />