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0'3/15/2016 12:24PM FAX 9528733112 f�0003/0004 Property address: 515_Ferndale Rd North,Wayzata, Mn 55391 Inspector iniGals/Date: JS � 3/10/2018 _ (mm/dd/YYYY) 4. Soil Separation—Compliance component#�4 of 5 Date of installation: � Unknown Verification method(s): (mmldd/YYYY) ShorelandlWellhead protection/Food beverage Soil observation does nof expire. Prvvious soi! Ivd �n ' �Yes �No observations by 1wo independent parties are su�cient, g �� unless site conditions have been altered or Iocal Com lianCe�riteria: reguiremenfs differ. For syst�ms built prror to April 9, 1996, and ❑Yes ❑ No � Conducted soil abservation(s)(Attach bonng logs) nof Iocated in Shoreland or Wellhead ProtectJon Area or not serving a food, ❑Two previous verifccations (Attach bonng logs} beverage orladging establishmeRt: CI Not applicable (Hofdinglank(sJ,no drainfreJd) Drainfield has at least a two-fo�t vertical ❑Unable to ve�fy(See Comments/Expfanation) separation distance irorn periodically ❑ Other(See Gomments/Explanation) saturated soil or bedrock_ Non-performance systems builf Apr!!9, �Yes ❑ No CommentslExplanatfon: 1996, or later or for non-performance sysfems located ln Shoreland or We/lhead Boring: Profection Aress or serving�food, 1-11" 10YR 2/2 Loam beverage, orlodging establishment: 12-15"10YR 4/4 CL Drainfieid has a three-foot vertica! separation distance from periadicalry redox found at 15" saturated soil or bedrocic.` "�xperimental", "Othcr';or °Pcrfvrmancc" ❑Yes ❑ No IltdiC�te de ths or elevatlo►1s systems built undcr prc-2008 Rulcs;Typc IV or V sysfems builf under 2008 Rcrles(7080. A. Bottom of distribu�ion media plus 21"or more _. .. . _ ---— 2350 or 7080.24�0 (Advanced Inspector l.iCc3nSC�eqUired) B. Perlodlcall saturated soiUbedrock OVef 15" brainfield meats thc dcsigncd vc�ical C. 5 stem se aration 36" lus separation distance from periodically saturated soil Qr bedrock. D, Re uired com liance so aration' 38" Any "no"answer above indicafes fhe sysfem 1s "May be reduced up to 15 percent if allowed by Locel failing to pro�ect groundwater. Ordinancc_ 5. Qperatin�, Permit and Nitrogen BMP*—Compliance camponen##� of 5 � Not applicable Is the system operated under an Qper�ting Permit? ❑Ycs ❑ No If"yes", A below is required Is the system required to employ a Nitrogen BMP? �Yes ❑ NQ lf"yes", B below Is requlred BMP=Best Management Practi�(s)spec�fied in thc systcm dcsign !f the answer to both questions is "no", fh/s sectfon daes no!need ta be comp/efed. Com liance criteria a. Operating Permit number: 0 Yes ❑ No Have the Q eratin Permit re uirempnts been met? h. Is the required nitrogen BMP In pl�ce and propQr) funr,tionin ? ❑Yes ❑ No Any"no"answer indicafes Noncompliance, Upgrade Requlrements(Minn.Stat.§ 115,55)An rmminent threaf to public heafth and safefy(lTPHS)must be upgraded.neplsced,orits use discontlnued wlthln ten months ot receipt af th;s noGce or within a st�orter penod if requrred by local ordinartce.!f the system rs fa;lrng ro protect grocmd water,the sysiem muat be upgraded, replaced, or its use disconhnued wifhin thc time requit�d bylocal ordrnsnce.li an existrng sysfcm Is not falling as defined ln law,and has atleast two feet of dQsfgn soll separal;vn,Ihen fhe sysldm nced no1 be upgradod,ropalrQd,roplaced,or its use diycontiniled, nohvifhStd»diAg arly lUca!Ordrnance that is mor�sfnct. This provisiorr does not eppfy to sysfems in shoreland areas, We/lhcad Protection ArBas,or those used in connectron with food,beverags, and lodging establishmcnts as defined in law. www.pcastaCe.mr�.us • 651•246-6300 • 800�657-384a • TTY 651-z8�-533Z or B00-657-3$64 • Available in alternative formats wq-wwists4-37 . 3/ibl 12 Pa e 3 0 3 S f