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Property address: _ OZ �'/Q �,L�,��/ CK�
<br /> �� 7��_ Inspector initials/Date:�,� p/,6`� �
<br /> ----. Tf-�4s
<br /> 4o So➢I Sep�ratiotl— Compliance component�t4 of 5
<br /> Date of in�tallafion: f°g c� �
<br /> ❑Unknown�- Veri�cation mefhod(s):
<br /> ShorelandNVellhead protection/Food Beverage '
<br /> �odging? ❑Yes �j No Soi/observation does not expire. Previous soil
<br /> Cor9�p17arlce Criteri�: obse�vations by Iwo independent parties are sufficient,
<br /> _ unless site conditlons have been altered or local
<br /> For systems built prior to Apnl 1, 1996, and ❑Yes �`No re9ui2ments differ.
<br /> not locafed in Shoreland or Wellhead
<br /> Profection Area ornot seniing a food, �Conducted soii observation(s)(Attach boring logs)
<br /> beverage or lodging establishment.� ❑ Two previous verifications(Atfach bonng logs)
<br /> Drainfield has at least a two-foot vertical ❑ Not applicable (Holding tank(s);no drain6eld)
<br /> separation distance from periodically ❑ Unable to verify(See Comment�Explanation)
<br /> _ saturated soil or bedrock. _ ❑ Other(See Comments/Explanation)
<br /> Non-performance systems built Apri! 1, �'Yes
<br /> 9996, orlaterorfornon-performance � NO Comments/Explanation:
<br /> systems located in Shore/and or Wellhead �� :'O `` J,4_N�'7 �a„�,,,.. �0 r,,R �r'��
<br /> P�otection A�eas orserving a food,
<br /> f�ri
<br /> beverage, orlodgingestablrshment: " ���� /��c.o�.••.� �,a,,,,,�y �ei�, �dr"' ��
<br /> t
<br /> Drainfield has a three-foot vertical 3� �- �sy°� rft�,,•,,� �¢",�7 c��?-� dOr°�� ��
<br /> separation distance from periodically /s
<br /> saturated soil or bedrock.* ���`�G �� ����"��' S.4�-�r (m.s.� omY�� �y
<br /> /yc�i'�!L a'o �t°� - /� L�cg X /l-1` �D t �6ir
<br /> "Experimenfal'; "Other'; or "Performance" ❑Yes ❑No --�
<br /> sy�,,,,-ns bur;f underpre-20U8 Fzcdes; Type!�1 I n�°���� de��y��$e{evaei�ns
<br /> or V systems built under 2008 Rules(7080. ��c�
<br /> 2350 or 7080.2400 /Arl��a.,�o,+ �.,............. A. Bottom of distribution media
<br /> . , �,..,Ni.�.�vi _-_._.
<br /> Lice�se requ;rcd)
<br /> Drainfield meets the designed vertical B Periodicall saturated soil/bedrock � � ��
<br /> separation distance from periodically C. System separation `�
<br /> saturated soil or bedrock.
<br /> — D. Re uired com liance se aration' �
<br /> e4ny 66��9f�rasvver a�iove ie�decafes the syste�n is �
<br /> Fajl;�7 go py�Ot��p��-����yy�t�� May be reduced up to 15 percent if allowed by Local
<br /> ---�—
<br /> ___ Ordinance.
<br /> 5e Ope7��tlfl� Per►r11t dnd �Ijgg-pg�� �/�P�_Compliance component#5 of 5
<br /> [.� ftfot applieabBe
<br /> Is the system operated under an Operating Permit?
<br /> ❑Yes ❑ No If"yes",P,belouv is required
<br /> Is the system required to employ a Nitrogen BMP? ❑Yes ��
<br /> ❑ No If yes", B below is required
<br /> BMP=Best Management Practice(sJ specrfied rn fhe system design
<br /> l�the answrer fo boti� questions is "rao'; this section does not need to be complefe�'.
<br /> Compliance criY�ria
<br /> a. Operating Permit number: -
<br /> Have the Operatinq Permit requirements been met� ❑Yes ❑ No
<br /> b. Is the required nitroaen BMP in place and properly functionin ?
<br /> ❑Yes ❑No
<br /> Aray 66�019 ansv�eri�dicates iVonco�npliance,
<br /> Upgrade Requirements(Minn. Stat. §115.55)An rmminent threat to publrc health and safety(1TPHS)must be upgraded,�eplaced,or its use
<br /> discontinued within ten months of receipt of fhis notice or wifhrn a shorter penod if requrred by loca!ordinance. lf the system rs failing to protect
<br /> ground water, fhe system must be upgraded, replaced, or its use discontinued within the time required by loca/ordinance.lf an existing system
<br /> is not failrng as de�ned in/aw,and has at/east two feet of design soil sepa�ation, then the system need not be upgraded,repaired,replaced, or
<br /> its use discontinued,notwithstanding any local ordinance fhat is more stricf. This provision does not apply to systems in shoreland areas,
<br /> Wellhead Protection Areas, or those used in connection with food,beverage,and lodging establishments as definari;R ia��,
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