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Property Address: <br />Busincss <br />Name.- <br />►`\a'; kz;o r- <br />Date! ti 9 _5t A. <br />5. <br />5. Soil separation -- Compliance component #5 of 5 <br />i°trll 544x' r-i.a <br />Date of installation i j, r :i t) -') <br />Unknown <br />(mmfdd/ <br />YYYY) <br />14�� * 1�p <br />3horelarid/Wei Ihead protection/Food ® Yes <br />beverage lodging? ❑ No Attached supporting documentation: <br />Compliance criteria select ane <br />Sa.Forsystems built priorto April 1, 9996, and <br />not located in Shoreland or Wellhead <br />Protection Area or not serving a food, <br />beverage or lodging establishment.- <br />Drainfield <br />stablishment:Drainfield has at least a two -foot vertical <br />separation distance from periodically <br />saturated soil or bedrock. <br />5b. Non-performance systems built <br />April 1, 9996, 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 -2006 Rules, - <br />Type IV or V systems built under 2006 <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 />® Soil observation 109s completed for the report <br />❑ Two previous verifications of required vertical separation <br />❑ Yes [] No* ❑ Not applicable (No soil treatment area) <br />❑ Yes ❑ No* Indicate depths or elevations <br />A. Bottom of distribution media qb-3 <br />B. Periodicail saturated soil/bedrock <br />C. System separation 3, 0 r� <br />D. Required com Bance separation* I 3 j0' <br />*May be reduced up to 15 percent if allowed by Local <br />Ordinance. <br />❑ Yes ❑ No* <br />*Any "no" answer above indicates the system is <br />failing to protect groundwater. <br />Describe verification methods and results: <br />Upgrade requirements: (Minn. Stat. § 115.55) An imminent threat to public health and safety f1TPHS) must be upgraded, replaced, <br />or ifs 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, 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 />https://www.pnD,StatE.mn.US 651-296-6300 800-657-3864 Use your preferred relay service Available in alternative formats <br />wq-wwists4-31b • 412812021 <br />Page 4 of4 <br />