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prop�rty►address: �`-�`a,�`L Ll����vcf A . L¢}, Inspector in�falstDate: �� Tc�.�-3-��.
<br /> 4. Soi! Separation--Compk€ance camponent#4 of 5
<br /> Date ai.lnstallatlon: I 1 -10—c� 1 ❑Untcnawn Veriflcat[on methad(s):
<br /> ShorelandANellhead protecttoNFood 8�verage �Yes �No Soil observaHon doss not expire.Prevlous sfllf
<br /> �odgtng� � o6servadons by two tndepe»dent partlas.ar�suffrcfent,
<br /> Com lia�ce criteria: un[ess slte cond�fons have been alfer�d or foca!
<br /> requ)�ements d►ffer. �
<br /> For systems builf ptfor b Apd!1, 7996, and ❑Yes ❑No
<br /> not focated In Shorelend or We!lhesd � Conducted safl observation(s)(Attach bortng logs)
<br /> Pr+ofectlorr Area ornot servfng a foad, ❑ Two previous veriftcatlor�s(Attach bodrx,�loc�s)
<br /> beverage orladgIng esfablishmen� ❑ Not applicable(Holding tank(s},no drainfte�d}
<br /> Drainfiald has at lesst a twafoat ve�fca! [j Unable to verl�y(Ses Commanfs/ExptsnafFar�)
<br /> separation disEance from periaiEcaVly
<br /> s�tura#ed soil or bedrock. ❑ �er(See Comments/Fxpfena#on}
<br /> lVorr�erfamarrce systems builtAp�11, �Yes ❑No Comrtrsnfs/Exp►attafian;
<br /> 1998,orlaterorfarnon-performance .
<br /> systems locafed fn Shoreland or We!lhead ���C`rk ) ��'� •
<br /> Protect�on Areas or serving a faod,
<br /> beverage, orlodging estabTrshmenf: . � . . •
<br /> Drainfield has a three-foot vettical
<br /> � separattor�dlstance fram periodicaliy '
<br /> saturated soil or bedrack.`
<br /> "Experfinenta!; 'Othe�`, or `Perforrnance" � ❑Yes ❑No tndicate de ths o#ele�atlons
<br /> systems built under pre-2008 Ru1es;Type N g�, • .g a,a.: •,��'s,�,.,�
<br /> or V systems b�11f under 2008 Rules(7080. A. Bottom of d(stribuUon media � � + �►a..S �,c�'��
<br /> 2350 or7080.2400 (Adv&nced Inspedor s�a j� a,3��-
<br /> �icense requir�d) g, padodic� aaturated�aiUbedrock St3�` �•5�
<br /> Drafnfiefd meets the designed�ertical C. S tem ae aratton 5�3`'1 3.I�, ,
<br /> sepa�atlan distance fi�om periodfcally
<br /> saturated soil or bedmck. p. R ulred com tlanoe se aratlon" ��'� �
<br /> Any"na"answer a6ove lndfcates#he system!s- #May be reduced vp to 15 percent if allawed�by Loca!
<br /> FalI1Rq to Profec#Groundwatei.____ : Ord�nance.
<br /> 5. Operating Pe�mit and Nttrogen Bt�AP�`--Compliance component#,5 of 5 [�Not appltcable
<br /> . Is#he system operated under an D�rati�g Perm3t? ❑Ye8 ❑No If"yes"�l4 befow is required .
<br /> Is the system required to emplay a 1Vitrogen BMP?• O Yes ❑No If"yes",B betow is required
<br /> BMP=Besf Menagemerrt Precdfce(s)spe�i�ied M the system deslgrr
<br /> lf the answer to both questlans!s"no';thls se�tlon does not need to be completed.
<br /> . ,
<br /> Cam liance criteria
<br /> . � ,
<br /> a. Operaf(ng PeRnEt number:
<br /> Have the O eratEn Pertnit re uErementa been met? ❑Yes ❑No
<br /> b, is ttie r uired nitro en BMP in face end ro fun�tloni 7 Yea No
<br /> Any "no"answer Jnd�c�tes Norrcornptfaaoe.
<br /> Upgrade Requlrements(Mlnn.Ste�§if5.b5}M 1mmUent thteet b p+rblJc health and sefety Q7PNS)must be upproaded,r�pJacod,or 1ts use
<br /> dfscanfinued wlthtn ten months of receipt of thfs notke or wlthfn a�r pe�tod if reQulred by local or�rnance,ff the system!s faFting to profect
<br /> pround wafer,!ha system mast be ctpQr&ded,ropfaced,orfts use dl9c�ntlr�d wlthin the t/me requlrod by toaaf ordinence.!/en exlsting system
<br /> !s not failing as defrned tn law,end has at feast!wp fest of d8slgi�SoI!seperst/op,fhen the System need not De upgr�aded,repalr�sd,raplaced,or
<br /> rts us8 dfscarttfrrued,nofwlthstemfhrg any bcef ord�anc�dret Is mo1B Jhfct Thls provJslat does nof epply to systems!n shoreland atiaas,
<br /> WeJlhead Profectian Ar�es or thass used In coru�ectfo►r yvtfh tood bever�qe,and lodglrts ast�bl(shm9rrts as deflned!n faw.
<br /> �cWW,�C�,S���,�1�t,t1S � b5��196�6�019 � 8�65�•3�! + � 1`CYb�i•2�t•�33�a��b5t�3�4 � dva�lab(e i�a(�ematfv�farma�
<br /> wq•w�vlsts4-31 • 1124/12 ' ' �
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