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Property Address: al ` \.# Business Name: ��ro✓f L J { 5. Soil separation —Compliance component #5 of 5 Date of installation (a - 19 - a 00 L, ❑ Unknown (mm/dd/yyyy) ShorelandlWellhead protection/Food ❑ Yes .M No beverage lodging? Compliance criteria (select one): 5a, For systems built prior to April 1, 1996, and ❑ Yes ❑ Noy not located in Shoreland or Wellhead Protection Area or not serving a food, beverage orlodging establishment-- Drainfield stablishment-Drainfield has at least a two -foot vertical separation distance from periodically saturated soil or bedrock. 5b.Non-performance systems built April 1., 1995, or later or for non- performance systems located in Shoreland or Wellhead Protection Areas or serving a food, beverage, orlodging establishment: Drainfield has a three=-foot vertical separation distance from periodically saturated soil or bedrock.* Date: - A V - 4 Attached supporting documentation: ® Soil observation logs completed for the report ❑ Two previous verifications of required vertical separation ❑ Not applicable (No soil treatment area) ❑ Yes 0 No- Indicate depths or elevatio A. Bottom of distribution medic 5c. "Experimental", "Other", or "Performance" ❑ Yes ❑ No - systems built under pre -2008 Rules; Type IV or V systems built under 2008 Rules 7080. 2350 or 7080.2400 (intermediate Inspector License required s 2,500 gallons per day; Advanced Inspector License required > 2,500 gallons per day) Drainfield meets the designed vertical separation distance from periodically saturated soil or bedrock. `Any "no" answer above indicates the system is failing to protect groundwater. Describe verification methods and results: I soil/bedrock 05 . `S 400 01P C. System separation I , l D_ Re aired compliance separation* *May be reduced up to 15 percent if allowed by Local Ordinance. Upgrade requirements: (Minn. Stat. § 115.55) An imminent threat to public health and safety (ITPHS) must be upgraded, replaced, or its use discontinued within ten months of receipt of this notice or within a shorter period if required by local ordinance. If the System is tailing to protect ground water, the system must be upgraded, replaced, or its use discontinued within the time required by 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 system need not be upgraded, repaired, replaced, or its use discontinued, notwithstanding any local ordinance that is more strict. This provision does not apply to systems in shoreland areas, Wellhead Protection Areas, or those used in connection with food, beverage, and lodging establishments as defined in law. https://www.pca.state.mn.us • 651-296-6300 800-657-3864 Use your preferred relay service Available in alternative formats wq-wwists4-31b • 4/28/2021