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- Property address: � /j/� ��f� �L ��/�L �� Inspector initials/Date; �%{ os'.7u ��- 4. SOiI Sepat-ati0ll— Compliance component#4 of 5 Date of installation: l�� Shoreland/Welihead protection/Food Beverage �Unknown Verification method(s): Lodging? ❑Yes , No Soil obseivation does not expire. P�evious soil Compliance Cpiterla' obseivations by iwo independent parties are sufficient, unless site conditions have been altered orlocal For systems built pnor to April 1, 9 gg6, and �9u�rements differ. not located in Shoreland or Wellhead Yes ❑No ,�,� Protectron Area ornot serving a food, �7 �-onducted soil observation(s)(Attach boring logsJ beverage orlodging establishment.� ❑ Two previous verifications(Attach bonng�ogs) Drainfield has at least a two-foot vertical ❑ Not applicable(Holding tank(s);no drainfield� separation distance from periodically ❑ Unable to veri fy(See CommentsiExplanation) saturated soil or bedrock. _ ❑ Other(See Comments/Explanation) Non perfo�rnance systems built April 1, >996, orlaterorfornon-performance �Yes No Commenfs/Explanation.• systems located in Shoreland or Wellhead Protection Areas orserving a food, 4�/� v �,�� /�� beverage, orlodging esfablishment: I oZ�m2y" �Aik �v�lrti Drainfield has a three-foot vertical �Q j 9 ` separation distance from periodically �� " �� ''4 t A��x� "��` saturated soil or bedrock.* "Experimental'; "Other'; or `Pertormance" systems built underpre-2008 Rules Type�� Yes o IndiCate depths of elevations or V systems built under 2008 Rules(7080. ----- ??�n�.�no��..,,,, A. BOYfOfYI Of riictrjhiitinn,.,Aa,� .<�� jniivdtiueti ulspect�r — ��4 /- �/ i.icense required) Drainfield meets the designed vertical B Periodicall saturated soil/bedrock ,,Z °� separation distance from periodically C Svstem separation saturated soil or bedrock. -- �`�� Any "no"answer above indicates the system is � Re uired com Iiance se aration' � Failin to Protect Groundwater. "May be reduced up to 15 percent if allowed by Local -- ___ Ordinance. 5e Operating Permit and Nitro en BMP* g —Compliance component#5 of 5 ' Is the system operated under an Orerating �ermit? P1ot appliCable ❑Yes ❑ No If"yes",,4 below is required Is the system required to employ a Nitrogen BMP? ❑Yes ❑No ��°�yeS�� g belowr is required BMP=Best Management Practrce(sJ specified in the system design l�the answer fo both questions is "no", this section does not need to be complefe�. Compliance criteria a. Operating Permit number. ---- Have the Operatin Permit require b n met? ❑Yes ❑No b. Is the required nitroqen BMP in lace and ro erl functionin ? Any "no"answer indicates Noncomplfarrce. �Yes ❑No _ Upgrade Requirements(Minn. Stat §115.55)An imminent threat to public health and safety(/TPHS)must be u discontinued within ten months of receipt of this notice or within a shorter pen'od if required by local ordinance. lf the system is failing to protect pgraded,�eplaced, or its use g�ound water, fhe system must be upgraded, replaced, or its use discontinued within the trme required by local ordinance. lf an existing system is not failing as de�ned in law,and has at least two feet of design soi/separation, then the system need not be upgraded, repaired, replaced, or its use discontinued,nofwithstanding any local ordinance that is more strict. Thrs provision does not apply to systems in shoreland areas, Wellhead Protection Areas, o�those used in connection with food,beverage, and lodging establrshments as defined in law. v✓ww.pca.state.mn.us = 651-296-6300 0 -_ w'q-wwists4-31 a y/Zq�� 800-657-3864 • TTy 651-282-5332 or 800-657-3864 ° Availabte in alternative formats Page 3 o f 3