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Prop�rfy address: 1 �.D 5 '�'�4-S�L�-�l. G'�'��G'o�- lnspector 1�111als/Date: d�� ��''�n-1.s� <br /> 4, Soil Separdtion—Compliance cpmponen##4 of 5� � � <br /> Date of.Installatlon: )a�f�t - E�� ��lnknown � Yerifica�lon method(s): <br /> ShoretandlWellhead praEectlonlFood Beva�age �YB5 ❑NO SO)f ObS9N&t(o11 dOeS►1ot eXp(re. P�9vJOcls 5oU <br /> �oa�ing� � observa�uns by fwa indepsndenf parties are suffrcient, <br /> Com liance criterla: unless stte conditions have besn atter�ed or locaf <br /> ?996,and ❑Yes ❑No �9ulr�ments dtffer. <br /> For sysfems buiJt prtor to Aprlt 1, � <br /> not tocafed in Short�land or 1Ne11head _ � Conducted soll observatian(s}(Attach boring logs) <br /> Profection Ares ornaf senring a foai, ❑ Two previous verificatIons(Attach boringlogs) <br /> beverage or lodgtng estabtishment: ❑ Not appl{cebfe(Holding tank(s),no draTnfield) <br /> Drainfleld has at teast a two-foot vertfcal � Unable to veclfy(Sea Comments/Exptenatlan) <br /> separation distance firom periodically ❑ Other(See Comments/Explanairon) <br /> saturated soil or bedrock. � � <br /> Non perfomrar►ce sysfems 6utitApril?, �Yes �.No . � Commsnfs/Explana6on: <br /> 1996,orlaterarfornon performance � <br /> systems locafed In Shoreland or Wellhaad � <br /> Pmfectlon Ar�as orserving a�food, • : <br /> beversge,arladging esfabllshmenf: . • . � � <br /> Drainfield has a three-foot ve�icat . <br /> separation distance irom perladtcally � ' <br /> saturated soil or bedrack' <br /> "Experimenta!'; °Other", or "Performance" ❑Yes ❑No lndiCate de ths of eievations 5�+5-9 a-� <br /> systems buitt underpra-2008 Rules;Type t4� s � - y,q—'_s��3-9 a. <br /> or V sys(ems 6ultf under 2008 Rules(7480. A. Bottom vf tl�tdbutton media � 56 y a st 5•+ sB�M 9�., <br /> 2350 or 7080.2400 (Advancad 1 nspector , � S��i�9�•�s s��y-�o z <br /> License requir�d) _ - . 8. periodlcail aatnrated solUbedrock ssa�3 q��� S%��"'"•3 <br /> D�ainfleld meets the designed verfical � sa ►�.s�s���,L�� se•s .9 <br /> C. $ t8R1.S8 SfBtIQR 5'(6r 3:a•)S73w�L�• <br /> separation distance from periodic�liy <br /> saturated soil or bedrock. D. uired com lfanca se aratlan' � 3"�� <br /> At?y "nQ"answer a6ove Indlcafes fhe systern Js• •May be reduced up to 15 peroent if ailowed�by Loca1 � <br /> Failing to Protect Groundwater. Ordtnance. <br /> 5. Operating Permit and N�trogen BMP�`—Compliance component#5 of 5 � Not applicable <br /> . is tha sysfem operated under an Operating Permit? 0 Yes ❑No; !f"yes",/�below is requf�ed . <br /> is#he system required to empioy a Nitrogen 9MP?• �Yes ❑No� !f"yes",B beiov+t is requlred <br /> BMP=Best Menegement Pr�ctice(s}specitied In the sysfem deslgn � <br /> ff the answer to both questlons ls«no",�fhls sectton.does not need to be compteted. <br /> , <br /> Com iiance crtteria <br /> � � <br /> a. Operating PeRnit number. � <br /> Have the 0 eratin �Permit r uirements baen met? ❑Yes ❑No � <br /> b. 1s ths re uired nitro en BMP in lacs arid �o ed furx�tonin ? Yes No <br /> Any"no"answerindlcates Noncomptlance. <br /> Upgrade Requirements(Mlnn.Stet§i 15 b5)An fmmfnent tbr+Bet do pubUc�asffh and safety(!TF?HS}must be apgraded,raplacad,or its use <br /> dtscantlnusd within ten months ofrece(pt of fhls natice or wffhln a ehorterperfod t!requlred by toc�f ordlnance.lf the system Is fai!(ng to pmiect <br /> ground weter,the systam must be upgraderf,replacsd,orits uss dlscon�nuad wlfhfn the tlme requJred bylorr�ondtna�ce.tf an axtsttrtg system <br /> rs noi feUing as defined 1n(aw,and hes at Jeast Mro faef of destqrt soll separetlor�,then�ha sqstem nsed r�ot be upgraded,rapeirgd,neplaced,or <br /> Its use dlscontfnued,notwtN�standlnp ar+y toca!onifnence that!s more strh�fi(s pinvlslon does notapply io systems fn shorefand arvas, <br /> We!lhead Protection A�eas,or those irsed In connectlon wr�h food,beversge,sndlod8ing establlshments as deflned ln faw. <br /> . .. . �.� ni.• i�nn nwr ir�v�n�� ' w��i�� www h��A--_AAw •�w�wi� i_-i�_��_ e_ _e._�_.:.._e__..__�_ <br />