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Oct. 22, 2012 11 ; 14AM No, 1004 P, 6 <br /> Property add�ess: 3 u Ivo (�•�J�C�:�+J 1,,,.�r, �0�.�<� Inspector initialslDate: ` v.�� aj�aS�1 z <br /> 4. 5oi l Separation—Complfance cvmpanent#4 of 5 <br /> Date of inatallation: � °j�j 7 ❑Unknown Verification method(s): <br /> shoreiandnn►ellhead protecNorv�ood eeverage �Yes �No Sol!�bservation does not explre. Prgvious soll <br /> Lodging� <br /> obs�nlafions by two lndependent par6es are suil79cient, <br /> Com liance crlte�a; unless slte conditions have been altered orlocai <br /> For sysl+ems buift pdor b ApN!1, 1�9B, end ❑Yes �No �Quirements differ. . <br /> not locafed in Shonsland orWellhead � Conducted soil observatlon(s)(Attach bor/nglogs) <br /> Protection Area or not se►ving a faod, ❑ 7wo previous verificatlons(Attach bo�ng logs) <br /> beve►age orlodg)ng establiahment' <br /> ❑ NOt appllceble(Molding tank(sJ,no dnafnfield) <br /> Drainfield has at leest a two-foot verticel (� Unsble to verify(Sse CommentslF.xplana�io�) <br /> sepsratfon disiance from pe�lodically <br /> saiurated soll or bedrock. ❑ Other(See Comments�cp�anatlon) <br /> •Non-pertoanance systema builtApMl 1, �Yes ❑ No Commenls/Explanadon: <br /> 1986, or leter or fot non-perforrn9nce <br /> sysfems/ocated in Shoreland or Wellhead <br /> Protection A►88s or serving e fo�al, <br /> beverage,or/odging estsblishment• <br /> Drainfield has a three-foot veriical <br /> separalion dlstenCe from periodically <br /> sekurat�d soil or bedrock,' <br /> "Experimenfal� pothe�', or "P�srformen�e� p Yes ❑No Indlcate de th�of elevatlo�s <br /> systems bullt under pr�2008 Rule.s; Type IV <br /> pr V systems built under 2008 Rules(7060_ A. Bottom of distrlbutlan media ����� <br /> 2360 or 7080.2400 (Advanced Inspector , <br /> Ucense tequirec� 1� 5 <br /> B. Periodicall salurater!soiVbedrock <br /> Drainfisld meets the designed vertical sS�+� �•�r � <br /> separation diste�ce from periodicaily �- S stem se aration „�,�:+�� ,.c� <br /> seturated soll or bedrock. D. R uired com liance se aratlon� �'� <br /> Any"no"answer above indlcates the syatem is *May be reduced up to 15 percent if ellowed by Locel <br /> Fallin to Protect Groundwater. Ordinence. <br /> 5. Operating permlt and Nitrogen BMP*—Compliance component#b of 5 � Not appiicabte <br /> Is ihe system operated under an Oper�ting Permit? ❑Yes ❑ No If"yes",A below is requlred <br /> Is#he system requfred to employ a Ni�rogen BMP? ❑.Yes ❑ No IF°yes", 6 belovY is requir9ed <br /> BMP=Bes�t Managem�nt Prec�ce(s)specl6ed in the system design <br /> If the answer to both queat/ons Is "no'; this secdon does not need to be comp/eload. <br /> Coin liance crlterla <br /> a. Operating Permit number: <br /> Have!he 0 eratin Perrnit re uiremenls been met? ❑Yes ❑No <br /> b, Is the re uired nHro en BMP in lace and ro tl functionin ? �Yes No <br /> Any"no"answer indicates Noncompl�ance, <br /> Upgrade Requlr�ements(Mlnn. Stat§115.55)An/mminent threat to publlc heslfh end sefety(ITPHS)must be upgreded,replaced,orlts use <br /> discontinued within ten months o/reaelpt of fhls notice or within a shorter perlod►(►equlred by local o►dinence.ff IFre aystem Is failing ta p�tecf <br /> ground water,the system must be upgraded,ropl�oed,or lts use dimoontinuad witbin the l/me requlred 6y loca,l ordlnance.Il an existing system <br /> is not!all/ng as de111�ed In Isw,and has at/east hvo feet o1 des�gn soil seperahon,then t/�e system rteed not be upgrsded,repe/red,leplaced,or <br /> its use disoontinued,notwKhstanding any/oce/o►dlnence thet Is more sd1cL Thls prov/sion does not epply fo systems in shaeland ereas, <br /> Wellhead Protection Areas,or those used Im m�necGon with faod,beveroge,ertd Fndging establisl��nents es defined in law. <br /> owu�tr n�� e�oFo mn ur _ LCA_�OL.[]M - OM t[7 70[� Tni i�• �m r��. _..w•w •���w.. . .. .. . .. .' ' <br />