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Property Address: IJ30 C,®x M <br />Business Name: _ r ` 4 1 {� ---_._ __. Date: (i41!S- <br />5. Soil separation —Compliance component 95 of 5 <br />Date of installation I 3 ❑ Unknown <br />(mmladlyyyy) <br />Shore Iand/WelIhead protectioniFood <br />beverage lodging? <br />Compliance <br />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 -foot 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 -2008 Rules; <br />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 />® Yes ❑ No Attached supporting documentation: <br />® Soil observation logs completed for the report <br />❑ Two previous verifications of required vertical separation <br />❑ Yes ❑ No" ❑ Not applicable (No soil treatment area) <br />11 <br />❑ Yes ❑ No' indicate depths or elevations <br />A. Bottom of distribution media 5���-9 d. . '� Sib�g <br />545 Ir i I, r,, <br />' �� �� •� B. Periodically saturated soillbedrock 5,, 3 _ @,I <br />C. Systern separation 51C f- I - ar V , of <br />D. Required cornpllance separationovoA t S U� <br />*May be reduced up to 16 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 (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 defrned 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.pca.state,mr.us 652-296-6300 800-657-3864 - Use your preferred relay service - Available in alternative formats <br />wq-wwists4-31b - 4/28/2021 <br />