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Oct 2 12 03:47p 763-213-0695 p.2 <br /> P operty address: / � ' y � :�c ; lnspector initials/Date: /G� ^ �,'���-- <br /> Soil Sepdration –Compliance component#R4 of 5 <br /> Date of instaffatiorr: ?q q,�—� ❑ unknawn Verification method(s): <br /> Shoreland/Wellhead protectioNFood Beve�age <br /> �od8��9� ❑Y� �N� Soi]observa6on does not expire.Previous soi! <br /> observations by iwo independent parties are suf�rcient, <br /> Co�'1 lianCe Criteria: unless site conditions have been altered orloca! <br /> For sysfems built prior(o April 1, 1996, and �Yes ❑No �Q�irements differ. <br /> not located in Shoreland or Wellfiead � Cond ueted soil observation(s) (Aiiach boring logsJ <br /> Proteciron Ar�a ornotseiving a food, ❑ Two previous verifications(Atcach boringlogsJ <br /> beverage orlodging establishmenf: <br /> ❑ Not applicable (Holding rank(s),no drainfield) <br /> Drainfield has at least a finro-foot vertical <br /> ❑ Una61e ta veriFy(See Commenis/Exp/anationJ <br /> separation distance From periodically <br /> saturated soil or bedrock. ❑ O�her(See Comments�Explanadon) <br /> Non performance systems builtAprrl 1, ❑Yes ❑ No Commer�fs/Explanation: <br /> j 1996, orlaterorfornon-performaRce <br /> systems located in Shor�fand orWellhead <br /> Protection A�as orse►ving a food, <br /> beverage, or lodgrng eslablishment <br /> Drainfreld has a three-foot vertical <br /> separation distance from penodically <br /> saturated soil or bedrock.` <br /> `Fxperimental; "Other; or `Perfvrmance" �.]Yes �No Indicate de ths of elevations <br /> systems buiff under pre-2008 Ru/es; Type I V � � <br /> or V sys t ems built under 2008 Rules(7080. A. Boltom ot distribution media <br /> 2350or7080,2400 (Advancsd Inspector ! <br /> LiCense requiCed) 8. Periodicall saturated soif/bedrock b <br /> Drainf�eld meets the designed vertical C. S tem se aration `� � <br /> ssparation distance from periodically <br /> saturated soil or bedrock. D. Re uired com liance se ration' �+ <br /> AI1y "no"answer above indicates the system is •�ay be reduced up to 15 percent if ailowed by Local <br /> Failrng fa Protect Graundwarer. Ordinance. <br /> 5. Operating �ermit and Nitrogen BMP*— Compliance component#5 of 5 Notappticable <br /> Is the system operaied under an Operating Permft? ❑Yes [� No If"yes",A below is required <br /> Is the system requfred to employ a Nitrogen BMP? ❑Yes �No If"yes", B below is req�ired <br /> BMP=Best MarragementPractice(s)spe�ed in fhe system design� <br /> / <br /> !f the ansbrer ta both questions is "no'; fhis section does/iot need to be camp/eted. <br /> J <br /> Com liance criteria �` <br /> a. Operating Permit number. � <br /> Have lhe O eratin Permit r uiremenis been mei? <br /> ❑Yes ❑ No <br /> b. Is the required nitroqen BMP in place and properly functio inq? ❑Yes ❑ No <br /> Any "no"answer indicates Noncomplia�ce. � <br /> Upgrade Requirements(JWinn. Stat.§115.55)An imminent thr+eat to public health and safety(ITPHSJ must be�pgraded,replaced,orits use <br /> discontinued within ten months ofreceipt of this not'ce or within a shoRer penod if required 6y loca!ordina►tCe. !f the system is failing to protect <br /> ground water,�he system mUst be upgraded,replaced,or its use discontinued wi(hrn fhe Gme reyuir�d by loca!ordinance. If an exis(ing system <br /> is not faiJing as defined in/aw, arrd has atlsast fwo feet of design soil separation,ihen ihe sysfem need not be upgraded,repair�d,r�p/eced,or <br /> its use dlscon6nued,nolwithstanding any loca!ordinartce that is more strict This provision does not apply to systems in shoreland a2as, <br /> Wellhead Protection Ar�as,orthose usecl+n oonnection with food,beverage,and(odging esfablishmenfs as de�ned in law. <br /> www.pca.state.mn.us • 65'k-296-630D • 600•657-3864 • TlY 651-282•5332 ar 800-657-3864 • Available in alternative formats <br /> uwiuwuirteA_77 _ f/'7A/17 <br />