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<br /> Property address: 4��} l ��.!��P?v�1�} 1.{� � inspector initials/Date: �.3`;-� {0 '1 "1- )Z_
<br /> 4. Soi l Sepa�dtiOn-Compliance component#4 of 5
<br /> Date of installation: J i �-t� -O 1 ❑ Unknown Verification method(s):
<br /> ShorelandlWellhead protectioNFood 8everage �Yes �No Soil observation does not expire. Previous soii
<br /> Lodging? observations by finro independent parties a�sufficient,
<br /> Com liance criteria: unless site conditions have been altered or local
<br /> requirements difl`er.
<br /> For systems builf prior to April 1, 1996, and ❑Yes ❑ No
<br /> not focated in Shoreland or Wellhead � Conducted soil observation(s)(Attach boring logs)
<br /> Protec6on Area or not serving a foocl, ❑ Two previous verifications(Attach boring logs)
<br /> beverage orlodging establishment:
<br /> ❑ Not applicable(Holding tank(s),no dreinfield)
<br /> Drainfield has at least a two-foot vertical ❑ Unable to verify(See Comments/Explenat;on)
<br /> separation distance from periodically
<br /> saturated soii or bedrock. ❑ �ther(See Comments/Exp/anation)
<br /> Non-performance systems built April 1, �Yes ❑No Comments/Explanation:
<br /> 1996, orlaterorfornon pe►formance ��+�� �¢,.i��l�f C-a�.c��:: �h•� -;�� „�-}�;'_
<br /> systemslocatedinShorelandorWellhead ovci ��..�f:.-�`ra-�,�?�..�� r.ao-� ,�.r�c'�GU�.P, 4e`;�,^ 5h��
<br /> Protection Ar�as or serving a food, � �! .�� ���ow�y b�,�,5 �u u r•� �1�, uJ�-��
<br /> beverage, orlodging establishment: tii� „��-(SL�:;�,�
<br /> Drainfield has a three-foot vertical
<br /> separation distance from periodically
<br /> saturated soil or bedrock.*
<br /> "Experimental'; "Othe�; or "Performance" ❑Yes ❑No indicate de ths of elevations
<br /> systems built under pie-2008 Rules; Type IV ss�r' �a,,-� . 'SYa�'��:�
<br /> or V systems built under 2008 Rules(7080. A. Bottom of distribution media 5��'�S � a,�, ,�,o's,4,.«�
<br /> 2350 or 7080.2400 (Adv�nced Inspector ;�+�2--a,�,'+
<br /> License tequired) B. Periodicall saturated soil/bedrock ST.���� - �,p�
<br /> Drainfield meets the designed vertical sc� i�3 8•1
<br /> separation distance from periodically C. S stem se aration �,+�a o
<br /> saturated soil or bedrock. D. R uired com liance se aration* 3,�
<br /> Any "no"answer above indicates the system is 'May be reduced up to 15 percent if allowed by Local
<br /> Failing to Protect Groundwafer. Ordinance.
<br /> 5. Operating Permit and Nitrogen BMP*-Compliance component#5 of 5 � Not applicable
<br /> Is the system operated under an Operating Permit? ❑Yes ❑ No If"yes",A below is required
<br /> Is#he system required to employ a Nitrogen BMP? ❑Yes ❑ No If"yes", B below is required
<br /> BMP=Best Management Prsctice(s)specified in the system design
<br /> If tlte answer fo both questlons is "no'; this section does not need to be comp/eted.
<br /> Com liance crlteria
<br /> a. Operating Permit number:
<br /> Have the O eratin Permit re uirements been met? ❑Yes ❑ No
<br /> b. Is the re uired nitro en BMP in lace and ro r1 functionin ? ❑Yes ❑No
<br /> Any "no"answer indicates Noncompliance.
<br /> Upgrade Requirenlents(Minn. Stat §115.55)An imminent threat to public health and safe[y(ITPHS)must be upgraded,replaced,or its use
<br /> discontinued within ten months of receipt of this notice w within a shorter period if required by loca!ordinanCe.If the sysfem is failing to protect
<br /> ground water,the system must be upgraded,replaced,or its use disc;ontinuad withln the time required by local ordinance.If an existing system
<br /> is not failing as defined in law,and has at least hvo feef of design soi!separatfon, then the system rreed not be upgraded,repai►ad,replaced,or
<br /> its use discontinued,norivithstanding any local ordinance that is more shict. Thls p�vision does not apply to systems rn shoreland areas,
<br /> Wellhead Protection Areas,or those used in connection with food,beverege,and lodging establishments as defined in law.
<br /> www.pca.state.mn.us • 651-296•6300 • 800-657-3864 • TTY 651-282•5332 or 800-657-3864 • Available in altemative formatr
<br /> we-wwists4-3 f . 1/14/f2
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