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Property address: 4755 Bayside Road, Orono MN 55359 Inspector initials(Date.'f� � 7/10/2014 __ (mmidd'YYYY) 4. Soil Separation — Compliance component #4 of 5 Date of installation: io/4/2000 ❑ Unknown Verification method(s): ��,�„idc��yyyyl Shoreland/Wellhead protection/Food beverage Soil observation does not expire. Previous soil lodging? ❑ Yes � No observaiions by two independent partres are sufficient, unless site conditions have been altered or/oca! ComplianCe Criteria: requirements differ. __ _ For systems built prior to April 1, 1996, and ' ❑ Yes ❑ No � Conducted soil observation(s) (Attach boring logs) not located in Shoreland or Wellhead Protection Area or not serving a food, ' ❑ Two previous verifications (Attach boring logs) beverage or lodging establishment ❑ Not applicable (Holding tank(s), no drainfield) Drainfield has at least a two-foot vertical ❑ Unable to verify(See Comments,�Explanation) separation distance from periodically ❑ Other(See Ccmments,iExplanation) saturated soil or bedrock ' lVon-performance systems builtApril 1, �Yes ❑ No Comments/Explanation: 1996, or later or fo�non-performance sysiems (ocafed in Shoreland or Wellhead ' Protection Areas or serving a food, ', beverage, or lodging establishment� Drainfield has a three-foot vertical ' separation distance from periodically ', saturated soil or bedrock.* ' _ __ Experimental", °Other", or "Perfonnance" ', ❑ Yes ❑ No (ndiCate depthS or elevations . _ sysiems buifi under pre-2008 Rules; Type N or V systems built under 2008 Rules (7080 , A. Bottom of distribution media elev.= 102.17 __ -_._ _ , . 2350 or 7080.2400 (Advanced Inspector LiCensc required) B. Periodically saturated soil/bedrock elev.=98.17 _ _ Drainfield meets the designed vertical I C. System separation > 3.0 ft. separation distance from periodically ; ' saturated soil or bedrock. D. Required compliance separation* 3.0 ft. _ _ _ _ Any "no"answer above indicates fhe system is *May be reduced up to 15 percent if allowed by Local tailing to protecf groundwater, ordinance. 5. Operating Permit and Nitra�en BMP* — Compliance component#5 of 5 � Not applicable Is the system operated under an Operating Permit? ❑ Yes ❑ No If"yes", A below is required Is the system required to employ a Nitrogen BMP? ❑ Yes ❑ No If"yes", B below is required BMP= Besi Management Practice(s)specified in the system design /f the answer to both questions is "no", this section does not need to be completed. Compliance criteria a. Operating Permit number. _ ---_ ❑ Yes ❑ No Have the Operating Permit requirements been met? ___ b. Is the required nitrogen BMP in placc and properly functioning? ❑ Yes ❑ No _ _ Any "no"answer indicates Noncampliance. Upgrade Requirements(Minn. Stat. § 175.55)An imminent threat to pubfic health and safety(Il PNS)must be upgraded, replaced, or its use discont+nued within ten months of receipt af fhis notice o�within a shorter period if requrred by local ordinance. lf the system is failing to protect ground wa[er, the system must be upgraded,reptaced,or its use discontinued within the time required by local ordinanca. /f an exisfing system is not failing as define.d in law,and has at least two feet of design soil separafion, ihen the system need not be upgraded, repaired, repfaced, or its use discontinued, notwithstanding any/ocat ordinance that is more stricf. This provision does not app/y to systems in shoreland areas, Wellhead Protectron Araas, or tfrose used in connection wrth food, beverage, and lodging establishmenis as detined in law. _ __—_ . ___ . __. www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in atternative formats wq-wwists4-31 • 3116/12 Page 3 af 3