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68/19/2014 15:49 9528733112 PAGE 03/04 Praperty address: 76b Dickey Lake Drl�e,�rono Inspector initials/DaYe: JS ( 8!1 M2014 _ _.__ (mm/Bd/yyyy) 4. SOiI $epdr�kion—Compliance compdnent #A-af 5 Date of installatian: 5l111994 �'] unknown Verlflcation method(s). (mm/dd/yyyyJ Soil Ob5ervation daes noi exprre.Previous soll SherelandM►allhead protectfanlFood beverage �YQg ❑Na pbseivations b two inde endent artles are sulflcrent, lodging? unleSs site cond/tfons ha e been altered orlocal Compliance criteria: requirements dlffer. For systems built prrOr to Apri!J, 1996, and I ❑Yes ❑No �Conducted eoil abservation(s)(Attaoh bor�ng bgs) not lOCat�d in Shor9land or Wellhead Profection Area or not serving a foorl, ❑�wa previous ver'rfiCati4ns(A�tach boring logs) bev�rage or loclg;ng establishmenr: i 0 NOt appliCable (NoJd�ng fank(s},no drairrhefd) Drainfield has at le�st a two-bot vQrtical I ❑Unable to�erffy(See GbmmentslExplanation) separation distartce from perSodically � ❑Other(See Comments/Dcplanallon) saturat9d sail qr bedrock. Non-performance systems burlt Aprr� 1, �Yes ❑ No Comc110ntS/�xplanatfon: 1996, or latar or fpr no»-perforrnance sysfems loCated in Shoraland or We!lhead Bonng:Confinned design boring& ProteCt�On Areas or serving a food, 1-12" 10YR 2/2 Loam b�verage, or lodgrng estsblishment: I 12-20" 10YR 4/4 Clay Loarn Drainfield has a three-foot vertical I separation diSt2nCe frqm penpdically Mo#Cs � 1 S" saturated soil or badrpck.* '� "Experimenta!", "Othe�', or "Perlormance" �Yes ❑ No IInd�Ca#e de #hs or elevetion5 systems buiR under pre-2008�7ules; '�}�e IV or V systems built under 2008 Rules(7080. A. Battam of distribution media lus 18" 2350 or 7080,2400 (Advanced Inspector l,iC�11S@ r2C�uired) B. Perlodically satur2t2tl saiUbedrOCk I 18° Drainfield meefs the deslgned vertical C. System separation ! 36" separation distance from periocfically saturated soll or bedrock. D, Requlredcomplianceseparation•. ! ._._36"________ A»y "ne"snswer above Indicates the sys#,em is "MaY be rgducad up to 15 percent if allowed by L.ocal fsiling io proteci groundwater. Ordinance. 5. Qperating Permtit and Nitrogen BMP�-- Gompliance component#5 of 5 I�I Nat appllc�ble Is tha System operated under an�perating Permlt7 ❑Yes ❑ No tf"yms°',A befow is reqUired Is the Syst6m rgquired to employ a Nitrogen BMP7 ❑Yes ❑ No ff"yes", B below Is required 6MP=Besf Man�gemsnt Pr�cf1ce(s)specrfied rn the system desrgn /f the an,�tiver M bofh questiorfs fs "no'", this section does»ot need!o be completed. Compliance criteria 3. Operating Permit numb6r: I ❑Yes ❑ Na Have the O eratin Permit re uireme�ts been met? b. Is the required nitrogen BMP in pl�ce andpropa�functioninq? i�Yes [� No Any"no"answer indicaies IVvncornpli�nce. Upgrade Requirements(Mlnn_Stat.§195.55)An imminent thre�t to publrC 11e81tit 8nd Safery(ITPHSJ must be upgraded,reptpced,or rts use dlscontfnued witYdn fen montJis ofYeCeipt of thi8 notrCe or wiihin 8�Sho+ter p6ripd 1(required by loca!oidlnance.!/�e system!s fa!ling to protecf ground water, tha systr�m must be upgrsded,reptsced,or its use d'rscanCinued wfthln the ffine raqufrad by local ordlnance.!f an exlsfing system ib not fail;ng as defined!n lew,and has a7/east two fee[of deslgn sa!!separatlon,then the sysfem need n0t b�upgYaded,repair�d,replACeCf,Or �7s use discortflnued,nohafthstandMg any local ordlnerrce thet fs more sMcl.Thls provfslon d0e5 r70f appJy to Sy5tem9 rn Sh01�Ipr1C al'@�5, Wellhead Protect/on Ar�as,or thase used in con�ection with lootl,bever&ge,artd lodgir7g e8t.�bJrBhmentg�S dQfirted in l�w. www.pta.SCdCe.mn.us • 651•29b•b300 � 860•657�3864 - 7TY b51-282-5332 or 800,657-3864 - Avaitable in altemative formats wq•wwiscs4-31 . 31 t6/12 Page 3 of 3