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� � � OGt, 12. 2012 10: 17AM No, 0962 P, 5 <br />� <br /> Properly address: ;l��` �� � �' Inspector inlUafs/Date: �,�+�- �J r��"L-1�-• <br /> �, 5oil SepaYation—Compliance component#4 of 5 <br /> �ft��u"�, I��i,�, <br />; Date of installatlon: 1�� �7 �D Unknown Veriflcation method(s): <br /> ShorelandlWAllhAad p�obecGoNFood Baverage Q Yes �NO Soil obse►vedan does not expire. PI'9vI0US SOU <br /> I LQde�"�� o6serva6ons by fwo independent pa►ties are suf�cient, <br /> Com lien�e C�lterle: u�Jess site aondiHons have been alte�d orloca/ <br /> requirements differ. <br /> For systems built pdor to April 1, 9996, and � Yes CJ No <br /> not locat�edln Sho�elend orWellhsad � ConduGted soll ob5elvation(s}(Attech boring IogsJ <br /> Prot�cBon Aree ornot se�ving a food, ❑ Two previous verifications(Aitach boring�ogs) <br /> � beverage o�ladging esreblishmenf: ❑ Npt$ppiiceble(Holding tank(s),no drelnfield) <br /> Drainfield has at leest a twafoot ve�tical 0 Unable to veriiy(See CommentslExp►enation) <br /> separation distance ftom perlodically 0 Other(See Commenfs�Eup/anation) <br /> seturated soil o�bedrock, <br /> Non-perfomtance syst�ms built Ap�111, ❑Yes [�No Comments/Expla�atlon: <br />� 1996,ar leter or for non performence <br /> systems located!n Shorelend or Wellhaad <br /> Protection Aress orserving a food, <br /> beverage,o�lodging establiahmenf: <br /> - Drainfield has a three-faat vertical <br /> separatlnn disiance from perlodlcaUy � <br /> saturated soll or bedrock.' <br /> Expe�lmental; "Othe�', o� "Pe►fo►m�nce" ❑Yes ❑No Illdfc8te de ths of elevations <br /> systems built underpre-Z008 Rules;Type IV `-g"" ' ���•� <br /> or V systems built unde�2008 Rules(7080. A. Bottom oF distribution media e�.>"`� � �i'�.4 <br /> Y350or7080.2400 (AdvBnced Inspector �:La 1�3•S' <br /> License required) B. Periodicall satureled aolUbedrock s;?,"� l,S� <br /> � DrainfielA meets the designed verlical '1'���`r �� �'�� <br /> separation dislanc�from periodically C, S stem se aration 5v 1°y x a• �•l� <br /> satureted soil or bedrock. = a.O/ <br /> D. R uirad com liance se a�etlon <br /> Any "no"answer above indieares the system is �May be reduced up to 15 percent if allowed by Locel <br /> FaJling to Protect Groundwater. Ordinance. <br /> 5. Operating Permlt and Nitrogen BMR"—Compliance component#5 of 5 � Not appllcable <br /> � <br /> Is the system opereted under.an Operating Permit? ❑Yes (]No If"yes",A below Is required <br /> Is the system required to employ a Nitrogen BMP? ❑Yes [� No If'°yes",B below is required <br /> BM�B�st Management Practice(s)speci6ed in the syslem design <br /> !f the anawer to both questlons is "ho'; this sect�on does not need to be comp/eted. <br /> � � Com liance cNterla <br /> a. Operating Permit number: ❑Yes ❑ No <br /> Have the O eralin PeRnit re uirements been met? <br /> � b. Is the r uired nitro en BMP tn lace and ro tl functionin ? ❑Yes ❑No <br /> Any "no"answer indicafes Noncomp/iance. <br /> i Upgrade Requlrements(Mlnn. Slat.§'115.55)An imminent threst to publlc heelth and sefety(ITPHS)must be upgraded,repleced,or its use <br /> dlscontinued Withln ien months o(raceipt Df tf1ls nOtice or wlthln a shoite�pBliod Il rer�uiied by loCal o/dln9nCo.If the system ie lall/ne to plufect <br /> � ground water,the system must be upgr�vded,►@p/eced,o�ita uae diSaontinued withln the Ume�squirBd by foce/ordlnence.I►en euristing system <br /> is not feiling as de�ned in lew,and has af►east two fesf of deslgn soi►sepereNon,fhen the system naed not be upgraded,rapeired,repleced,or <br /> ffs use d�scontlnued,nofwlthstanding any/ocal ondlnence thet is more sMct Thls provlsion does not apply to sys[ems in shoreland erees, <br /> Wellhead Profectlon Aress,or those used In connection with loal,beverege,aRd lodgine establishments�s defined in law. <br />