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Prop�rty address: 3�'i s Ll-�nZ�L�.a.� '�,7�- � c�4-��.c� Inspector Wtiaals/Dale: ` /v�'ao-�� ' <br /> 4. Soit Separation—CompGance componer�t#4 of 5 <br /> Date af tnstallation: ! J q�a( ❑Unknvam VeriRca#lon method(s): <br /> lodytnrefandlwettt+ead pro�tfontFood Sevsrape �Yes ❑No SnJI obse�vation daes not axpJr�.Pnavtous soN <br /> obsenratfons by two lrtdepende�f partfes are sufl5cfent, <br /> Com Ilance ct�teria: unless slte c�ondr�ons heve�een aJtered or-bcaf <br /> For sysfems buJ/t pr�or to Ap�i!1, 1996,ar�d ❑Yes ❑Pla �j��a ditler. <br /> noflncatedln ShoreJand orWellhhesd � Conduc�ed soil obser�ation(s)(Attact,boring�ogs} <br /> Profecdion A�ea ornot serving a food, ❑ Two previous ve�ons{Attadr bor�n9�1 <br /> beverage orlodging est�Wtshment: <br /> Drainfleld has at ieast a twafoot vertEcxil � µOt applicable{Ho�ng tank(s},no�nt►efd} <br /> separation distance�rom pe�iodlcaily ❑ Uitable to verity(See Comment�xptanatkn) <br /> saturated soif or bedrock. ❑ Othe�(Ses c.anments/Explena�on) <br /> Nor�-perfom►ance aystems bullt Ap�i1 i, �Yes ❑NQ Comments/Explanatlon: <br /> 9998, or/aherorfiornon pe�mence <br /> systems locafed!rr Shae/and or Wephesd <br /> Pr+�tecUon A�as orssrving a fiood, <br /> beverege,orlodgingesfaWishmertt: . <br /> Drair�fleld has a thr8e-foot vettical <br /> separatton dtstance from pe�iodicai�r . <br /> saturafed soil or bedr+odc.` <br /> °Expedmental", `Othe�',or •Perfomrancaa' � ❑Yes ❑No lndicate de of elevadons <br /> systems built undsr p�s-2008 Rules;Type IV .. <br /> or V systems buNt under 20a8 Rules(7080. A. �ottom of dtsMbution media �'l+�'"d 9�•� <br /> 2350 or 7080.2400 (Advanced inspec;tor � s�� t � �•L. ��.o'sa.�� <br /> Lic�ense requir�d) B. Peri satu�abed soiVbedrodc s�rb�a- �, l-�'s+a�*�,� <br /> �rainfield meets the desEgnecf vertical C. tlon 5��`L- y.c,�� , <br /> separation distanoe frorn periodfc�lty ' <br /> saturated soil or bedrock. 0. ulred Ilance n� �'�/ <br /> Any"no"answer above fndlcatss the system!s� *May be reaucea up to 1�percent ff a�towea by�oca� <br /> Faliing fo Profect Groundwater. ordinance. <br /> 5. �perating Permit and Nitrogen BMP*—Complianoe«�mmponent#5 0#5 ■Not applkable <br /> . Is tbe system operated under an Opera�ng Pertnit7 ❑Yes ❑No !f"yes"�A b�low�requlred <br /> Is the system requlred to employ a Nitrogen 6MP?� O Yes ❑Na N"yes"�8 below is requfred <br /> BMP�Best Menag�merrt Pr�cb'ce(s)apec�if'ied br the sy,�m deslgn <br /> K the answer to both questlons ts"no;thts aecdon does nof need to be completeal <br /> � <br /> COtit I18RC@ C!'It@rIe <br /> a. Operaling Perm�number: ' <br /> Have the O eratl Permit uirements been met? ❑Yes ❑tVo <br /> b. Is the uired en BMP in (aoe and ro furx�Ionin � Yes No <br /> Any"no"answerina�cates Noncomptfance. <br /> Upgrade Requframertts{Mlnn.Stet§1�5.68)M lmmhreM threetb pubRel�alth and aefe(y(ITP.HS)»nist De uP9rgded,�eplaced,orlts use <br /> �scb�nued w�bt ten mortfhs of recelpf�this nntics or w�thb�a shorter perlod lf reyWr+ed bY Mcel av�nance.lf the aystem!s fapin8 to proted <br /> �nrouund wafer,the system rnust be upgradeQ replececf,ar Ks use dieoondnu�d wldrhr the thne requlr�d by bca!ordinanae.!f an exlsth�g system <br /> is��nr,��s�nee�,tsw,andne$8��east rwo r�erad�►,scn�e�uon,rnen r�aysrem�d nac be u�►aaed,re�rred r�►8�ea,or <br /> ns use�ued,�vl�andh�9 a►�Y!xa!ordh►a►�e thatls more sbh.�Thls pr�visJa►does not e�ply to aystems fi shore/snd areas, <br /> Wellhead Profedfon A►+9es,ar those used in connect�on wlth fbod.beaera�B,end fodg�fi�g establ�hments as deffned&�law. <br /> www,pCB,St��e,mn,uS • 65l•29fr6�0 � 800-b5/-3864 • 1TY 651-28't•5332 or 800�b57•38b�4 • Avail�h�e�t attemative formatr <br /> ,�-wwtsc�r-3 r • f/24/J2 � . <br />