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� ' _. Property address: 2450 Countryside Road _ Inspector initials/Date: RP � 6/4/2015 (mm/dd/yyyy) 4. Soil Separation — Compliance component#4 of 5 Date of installation: 6/4/2015 ❑ Unknown Verification method(s): (mm/dd/yyyy) ShorelandNVellhead protection/Food beverage Soil obseivation does not expire. Previous soil lod �n � ❑ Yes � No observations by iwo independent parties are sufficient, g g' unless site conditions have been altered or local Compliance criteria: requirements differ. For systems built prior to Apnl 1, 1996, and ', ❑ Yes ❑ No ❑ Conducted soil observation(s) (Attach boring iogs) not located in Shoreland or Wellhead I Protection Area or not serving a food, ' ❑ Two previous verifications (Attach boring logs) beverage or lodging establishment: ❑ Not applicable(Holding tank(s),no drainfield) Drainfield has at least a two-foot vertical ❑ Unable to verify(See Comments/Explanation) separation distance from periodically I ❑ Other(See Comments/Explanation) saturated soil or bedrock. ' Non-performance systems builtApril 1, , ❑ Yes ❑ No Comments/Explanation: 1996, or later or for non-performance i systems located in Shoreland or Wellhead I This page does not apply, New system Protection Areas or serving a food, II beverage, or lodging establishment: , Drainfield has a three-foot vertical I separation distance from periodically ' saturated soil or bedrock.* "Experimental'; "Othe�", or "Performance" ❑ Yes ❑ No IndiCate depths or elevations systems built under pre-2008 Rules; Type IV ' or V systems built under 2008 Ru/es(7080. A. Bottom of distribution media ' 2350 or 7080.2400 (Advanced Inspector I LiCense required) !I B. Periodically saturated soil/bedrock Drainfield meets the designed vertical I C. System separation separation distance from periodically � , saturated soil or bedrock. ' D. Required compliance separation` Any "no"answer above indicates the system is *May be reduced up to 15 percent if allowed by Local failing to protect groundwater. Ordinance. 5. Operating Permit and Nitrogen BMP*— Compliance component#5 of 5 � Not applicable Is the system operated under an Operating Permit? ❑Yes ❑ No If"yes",A below is required Is the system required to employ a Nitrogen BMP? ❑Yes ❑ No If"yes", B below is required BMP=Best Management Practice(s)specified in the system design If the answer to both questions is "no", this section does not need to be comp/eted. Compliance criteria a. Operating Permit number: ❑Yes ❑ No Have the O eratin Permit re uirements been met? b. Is the required nitrogen BMP in�lace and properly functioning? ' ❑Yes ❑ No Any "no"answer indicates Noncompliance. 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 failing 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. www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Availabte in alternative formats wq-wwists4-316 • 6/4/14 Page 3 of 3