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Property Address: r) t? 5 <br />Business Name' - S - 4> > <br />Q <br />S. Soil separation — Compliance component #5 of 5 <br />Date of installation L9 g i ❑ Unknown <br />(mmlddlyyyy) <br />Shore I andMell head protection/Food <br />beverage lodging? <br />criteria (select one): <br />❑ Yes ® No <br />5a. For systems built prior to April 1, 1996, and .N Yes ❑ No* <br />not located in Shoreland or Wellhead <br />Protection Area or not serving a food, <br />beverage or lodging establishment; <br />Draintield has at least a two -foot vertical <br />separation distance from periodically <br />saturated soil or bedrock. <br />5b.Non-parfomtance systems built ❑ Yes ❑ No" <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, or lodging establishment. <br />Draintleld has a three-foot vertical <br />separation distance from periodically <br />saturated soil or bedrock.* <br />5c. *Experimental", "Other", or "Performance" ❑ Yes ❑ No* <br />systems built underpre-2008 Rules; <br />Type 1V or V systems built under 2008 <br />Rules 7080. 2350 or 7080.2400 <br />(intermediate inspector License required s <br />2,500 gallons per day; Advanced Inspector <br />License required > 2,500 gallons per day) <br />Dralnfield meets the designed vertical <br />separation distance from periodically <br />saturated soil or bedrock. <br />*Any "no" answer above indicates the system is <br />failing to protect groundwater. <br />Describe verification methods and results: <br />Date: 9-- eg — <br />Attached supporting documentation: <br />® Soil observation logs completed for the report <br />❑ Two previous verifications of required vertical separatlon <br />❑ Not applicable (No soil treatment area) <br />❑ <br />"May be reduced up to 15 percent if allowed by Local <br />Ordinance. <br />Upgrade requirements: (Minn. Stall. § 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 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 />5� <br />https:/lwww,pta.state.rnn.us 651-296 6300 800.657-3864 Use your preferred relay service Available in alternative formats <br />wq-wwists4.31b • 412812021 <br />Fa0e 4 of4 <br />