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Property address: 4220 Chippewa La Orono, MN 55359 Inspedor initials/Date:� � 12/16/2015 (mMdd/yyyy) 4. Soil Separation—Compliance component#4 of 5 Date of lnstallation: 1/9/9979 ❑Unknown Ve�cation method(�): �mM�y� Sal observation does rat expire. Previous soil Shore�andANellhe�d pnotscrioNFood beverage �Yes � No observations by iwo independent parties are suMiCient, ��+�� unless sit+e conditions have been altered or local Compliance criteria: �equi►ements ditTer. For systems built p►tor to Ap�ii 1, 1996, and ❑Yes �No �Conducted soii observation(s)(Atted►bo�ing►ogs) not located in Shoreland or Wellhead Protection A�ea or not se�ving a food, ❑T�previous verifications(Attach baing bgs) beverege or lodging establishment ❑ Not applicable(Holding tank(s),no drair►fiek� Drainfield has at least a 1wo-foot vertical ❑ Unable to verii�r(See Car,mentsiExplanation) separation distance from periodically ❑Other(See CommentsiEup/anaUon) saturated soil or bedrodc. Non-pe�famance systems buiR Apri11, ❑Yes ❑No Comments/Explanation: 1996, or later or for nor►�erfoimance If a drair�ield is in the backyard it is assumed tl�e bottom of systems bcated in Shoieland or Weqhead Piotection Areas orserving a fuod, rodc is 24 inches based on the depth of tanks at 8 inches beverage, or lodging establishment: under grade. Drainfield has a three-foot vertical separation distance from periodicaliy saturated soil or bedrodc." Ekperimental'; "Other^, vr Pier�brmance' ❑Yes ❑No Indicate depths or eievadons systems built under pie-2008 Rules; Type IV or V systems built under 2008 Rules(7080. A. Bottom of distribution media assumed 24" 2350 or 7080.2400 (Advanoed Inspedor License required) B. Periodical saturated soivbedrodc 30"and 28" Orainfield meets the designed vertical C. S tem se araUon 8"and 4" separation distance from periodically saturated soil or bedrock. O. R uired com iance ration' 24" Any "no"answer a6ove indicates the system is '�Y��uced up to 15 perc�errt if allowed by Local failing to protect groundwater, o�d'"a"ce_ 5. Operating Permit and Nitrogen BMP'�—Compliance component#5 of 5 � Not applicable Is the system operated under an Operating PermiY? ❑Yes ❑ No If"yes",A below is required Is the system required to employ a Nitrngen BMP? ❑Yes ❑No Ff"yes",B below ia requir+ed BMP=Best Management Prac6ce(s)specifisd in the system desrgn If the answer to both questions is "no", this secdon does not need to be comp/eted. Com liance criteria a. Operating Permit number. ❑Yes ❑No Have the O rati Pertnit r uirements been met? b. Is the uired n' en BMP in ace and ri fundioni ? ❑Yes No Any"no"answer indicates Noncompliance. Upgrade Requlremetrts(Minn.Sfat§115.55)An imminent threat to public health and safery pTPHS)must be upgraded,replaoed,orits use discondnued within ten months of rsc.eipt of this notice or within a siarter peiiod if�equired by local adinar►ce.lf dre system is failing to protect ground water,the system must be upgraded,�ep/aced,or►ts use disoantinued wrthin the 6me�equired by bcal ordinance.lf an existing system is not failing as defined in law,and has at least Mro feet of design soil separeA�or►.then tl�e system►►eed not be upgr8ded.reP��,�P��,°'� its use disoarGr►ued,iafwifi►stend"u►g any bcaf adir►ance thet is more sLict This provisim dbes not epply do systerr�s in shaalend areas. Wellhead P►otectia►Areas,or tiase u.9ed in connecbon with food,be►�ia9'e,and lodgii�9 e�hments as defined a►law. www.pca.scate.mn.us • 651-296-6300 • 800-657-3864 • 1TY 651-2ffi-5332 or 80o-657-3864 • AvailaWe in alte�rnative formats .---.._..._._. �.� _ �,.,.. Poge 3 of 3