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Prap�riy addr�ss: ��1 y C� ���.. 'c�-��S � Inspectar initiais/Date: �-�-,����.�} -7� �,�� <br /> 4. Soil Separation-Compllance c�mponent#4 of 5 � <br /> , , <br /> Date of instaflation: _�u c2;� ��n�� ' Vertficatton method(s): <br /> ShoreiandMleNhead protsctlorelFood 8everage Q Yes ��l0 Solf abservaHon does noi explre.Prevlous sal! <br /> �od9En9� � observa�ons by iwo lndependent partles are suffrcienf, <br /> Com liance criteria: � unless slte condi�ons have been altered orlocal <br /> raequtrements dfffer. <br /> For systems buflf pdor to Apr111, 1996, and ❑Yes ❑No - <br /> nof 14cafed in Shor�lend or 1Ne!lhead � Conducted soil observation(s�(Attach borJng Iogs) <br /> Profacflon Area or nof serving a food, ❑ Two previous verificatlons{Attach boring logs) <br /> bever�ge orfaiging esfabllshmanf: <br /> ❑ Not applicab4e(Holtiing fank(a),no dralnfield) <br /> Drainfield has at Eeest a two-foot vert{ca! (] Uasble to vetity(Ses Commenis/Eaplenatlar) <br /> separation distance fram periodlcatly <br /> saturated sail or bedroc[c. ❑ Other(See Comments/F_xplaneflon} <br /> Nan-pe�farmarrce systems bvrltAprrf?, �Yes �.No . Commenis/Explanation: <br /> 1996,orlaterorfornothp9rforrnance <br /> sysfems locafedln Shoreland or Wellhead <br /> Profectlon Ar�es ar serving a food, • , <br /> bever�ge, ar.lodging esfab!lshmenf: . • . � � <br /> Drainfield has a three-foot vetiicat <br /> separatfon distance from perEaf(catly � • <br /> saturafed soil or bedrock.R <br /> "Experfinental; "Ofhe�; or "Performance' ❑Yes ❑No Ittdicate de ths qf elevatlotts <br /> systems buiJt under pre-2008 Rufes;1'yps!1f� q3,3 uo s��a� <br /> or V sysfems bullf under 2008 Rules(7�80. A. Boftom o#�latdbutton medla t, � .A .�p <br /> 2350 or 7080.2400 (Advanced lnspectar � � <br /> L{cense requir�d) - B. Pariodtca![ asturatedsa[Ubedrock ���5�'� <br /> Drainflefd meets fhe designed vertical C. S tem.sa aratton v `�� 1 �4 J <br /> separatfon distance from periodicaqy � <br /> saturated soi!or bedrock. � <br /> 0. R ufred cmn Ilance se a�a8on• �'� � <br /> �1ny "no"answer a6ove lndlcafe.s #he sysfem is� �May ba reduced up to 15 pe�cent if allowed-by l.ocal <br /> Failing to Pro#ect Groundwater. ordEnance. <br /> 5. Operating Permit and.Nitrogen BMP*—Comptlance component#5 of 5 � Not applicabte <br /> . Is the system opetated under an Operating Pertr�Ef? []Yes ❑No; If"yes"��k belaw is requlred . <br /> Is#he system required to employ a Nitrogen BMP?• [7 Yes ❑No� lf"yss"�S below is required <br /> BMP�Best Menegement PrecHce(s)speciqed M the system deslgrt <br /> ff fhe answer to both quest�ans ls"r�a'.; thts sectron.does n�st need to be compteteaf. <br /> , <br /> Com liance cdteria <br /> a. Operattng Permlt number: � ` <br /> Havs the 0 eratln �Permk re uiremenfs heen met? ❑Yes ❑No � <br /> b, is the re uired nitr en SMP In �lace and ro fimctionln ? Yea No <br /> Any"no"answerindicetes Noncomptlence. <br /> Upgrade Requirements(Mlnn.StaL§1 i5.55)An lmmfrtsn!threat to pubrl��eelth and saiety(lTPHS)must be upgraded,replaced,or rts use <br /> dlscon�nusd wtth)n ten months of recelpt of thls notke or wffhfn a shorter period NrequJred by focel ot�Onenca.tf the sysfem!s fall(np!o pmtect <br /> ground water,the system must be upgraded,repJac�ed,orlts usa dls�on8nued wtthln fhe tlme�equ[red by loca!ardlnance.lf an exlsting system <br /> !s not fe!!!ng as deflned Jn law,and hes af.feest hsro faet of destgn so1J SepareUo�,thsn�he system rteed not be upgraded,ropafrtsd,►�eplaced,or <br /> !ts use dlscor►flnued,nah�vlfhstandh�p eny foc.�el ortilnertrx thet!s rnore strfcL 7'hls piaWaron does noteppfy!o systems!n shoraland areas, <br /> Wellhead Protecfton Areas,or those irsed ln conrrecffon wlth food,beveraQe,and lodging astabllshments as deflned fn!aw <br /> YdY�V�.ACA.Sti��e,fllll,llS � �5�•�����3� � �-��1•�8� � T�6S�Za1•5332 or 8fl0-b57•3�64 • b,vallabte in alfemattve tormats <br />