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" May, 14, 2013 10: 12AM ti`o, 1696 °, 5 <br /> � prop�rty addr�ess: �� �ouvi� . 'v� ' Inspector initials/Date: ` ��J t — <br /> 4. Soil Sepa�dtion--Gompliance c�mponent#�of 5 <br /> Date of installation: �°l°13 _ ❑Unknown Veriflcatlon method(8): <br /> SnorelandlWelihead protecUoNFood 9evernge �Yes �No So1�obse►vafion does not explre.1'revfous soJl <br /> Lodging2 obs�Nations by two in0ependent pe�res sre suf�icient, <br /> COm IianGe crlteria: unless site condrtions have been alter�d orloca! <br /> requirements diCfer. <br /> For systems built pdar to Aprif i, 1�9b, end [�Yes [1 No <br /> not focated in Sha�fand or Wellhead � Gonducted soil observatian(s)(Attach bo►�ng logs) <br /> ProteCHon Anaa or not serving 8 Il�od, ���S [_] Two prevlous�erifications(Aifach boring fr,gs) <br /> beveraga or lodging establishment.� . {] Not app4tcebfe(Holding tnnk(s},no dra(nflefd) <br /> '�-V <br /> Dralnf+etd has at least a twafoot verticak ❑ U�ab1�t4 verify(See Commenls/Exp�anerlon) <br /> separation dlstance ftom perfodically ❑ Other(Sea Comments/E'xplanation) <br /> saturated soll ar badrock. <br /> Non-perfa�rnance systems built Aprif 1, ❑Yes (]No Commenfs/�xplanation: <br /> 1996,or lafer or far nnrrparformence <br /> systems loceted in Shoralend or Weflhead <br /> P�otecfron Ar�as or se,ving a taod, <br /> bevert�ge, orladgfng estabGshmant' <br /> Drainfi�ld hes a three-taot vertical <br /> separatlon dlstance irom pedadlcelly <br /> seturat�d soll or bedrock." <br /> "�xpsrimental" `Othe�',or "Performance" ❑Yes ❑No Indicate de ths Of eleVdtlotts <br /> systems bufft underp�2008 Rules;Type!V sax� iu a,�4 ra� 5 <br /> or V systems built under 2008 Rulas(7a80. A. sottom ot d�s�rtbunon media s�•a i o x,4 e io�.•s � <br /> 2350 or 7080.24U0 (Advanced Inspectar S�`� ��� <br /> License�equired) B. Period3call saturatea soiVbearock st�°�d ��• <br /> Drainfield meets the designed vertical s��� � �-���0 3. <br /> C. S stem se aration s5b'I - ��u`'(.3•7 <br /> separation distance from periodically <br /> saturated soil or bedrock. D. R ulred com lianca s� atation• �'�� <br /> Apy"no"AnsWer a60VA IfldfCer08 t11@ Sy8�@l►1 IS �May be reduced up to 15 percent If allQwed by Locai <br /> Farlin to Protect Gra�ndwater. Ordinance. <br /> 5. Operating Permit and Nitrogen BN1p*—comp�i�nce component#�of 5 � Not applicable <br /> Is the system oparated under an Operating Permit? �Yes ❑No If"yes",A below la requfred <br /> Is the sysiem required to employ a Nltrogen gMP1 []Yes ❑Np If"yes",B below Is requlred <br /> 8M1'=Best Menagement Pr�c#ce(s)speci�ied in the sysfem deslgn <br /> if the answer to both questlorfs ls "no",fhls s�ctlon does not need to b�completed. <br /> , <br /> Cbm iiance crlterfa <br /> a. Operating Pemtit number: 0 Yes [�No <br /> Have the 0 eratin Petmit r uirements been met? <br /> b. Is the re ulred nitra en BMP in lace and ro eri funcfilonin ? Yes ❑No � <br /> Any"no"answer indlcates NoneampJlance. <br /> Upgrade Requlrements(Mrnn.Stat.§115.55)M imm►nent threat to pu41�C healfh and sefety(ITRHS)must be upgraded,replaaed,or i!s usa <br /> dlscar�tinued wlUiln t�n months of raceipt of�Is notke or wlUr(n e shorter pedod!f requlred by(oca!ord�nance_rt the system!s falling to protect <br /> ground water,the system must be upQraded,repleced,or Ita us�disaontlnu�d wHhln the time requlred by foca,l ardlnance.lf en exlating aystem <br /> is not!a!ling as defined!n law,and hes at least fWo leet of deslgn s01!separaflon,t�►en t�e system need not be upg►aded,r�pefred,replaoed,or <br /> Ffs uae dfscontinued,nohvfthstanding any locdl Ominanoe thet Is more sMCt 77i1s provlslon doe�no!appfy b systems In ahonatend areas, <br /> Wellheed P►otecNon Areas,or those ussd 1n connection w1Ht food,bevere9e�end fodQf»q eBfBbllshments es dafirled 1»18W. <br /> www.pca.state,mn.us • 651•29b-6300 � 800-657-3864 • TfY 651•28Z-5332 qr 80p-65y-386G • Available in altemative formeFs <br /> wq-►vwlsts4-J1 • !1241 f2 <br />