Laserfiche WebLink
' Propertyaddress: 4S L,ovokti.l��.�J � Inspectorinitfals/Oate:'Lj/��. q-�a,q-)� <br /> 4. 5oil Sepd�dtiOtl—Compliance component#4 of 5 <br /> Date oi installation: _ �'q�� ❑���� Verificatton method(s); <br /> Sho�landlWellhead pmtactloNFood Beverage �Yes �No Solf observatlon does not expire.Prevlous soil <br /> LodyingT <br /> observatlons by two independent parties a�u stdlfderM <br /> Com Ilance C�itetia: unless site condltfons have been altered or loca! <br /> Forsystems built priorto Apri11,1996,and ❑Yes �No +�4uf�ements dllFer. <br /> not located M Shoreland orWelfhead �Conduded soil observation(s)(Attach borrng loqy� <br /> Protection Area ornot servfng a food, Q Two prevlous verifications(Anacn oodng roas� <br /> beveraqe orlodgfig establlshment: <br /> ❑ Not appliceble(hlolding tenk(s),no d.alrMel� <br /> Drainfteld has at teast a two-foot veRical ❑ Unable to verify(See Comments�icplaneBon) <br /> separetion distance firom periodically � ������� <br /> saturated soii or bedrock. plenaUon) <br /> Non�eAormance systems buiMApri11, 0 Yes ❑No CommentsiF�cplanaGon: <br /> 1996,orlaferorfornor�-petfprmance <br /> systems located In Shorelartd or Wellhead <br /> P�otecUon Areas or serving a food, <br /> beverege,orlodgingesteblishmenh. <br /> Dreinfield has a three-ioot vertical <br /> separaIIon dfstanoe from periodically <br /> saturated sal or bedrodc.• <br /> Expedmental''Other or PeAo►man�e^ Q Yes ❑No Indlcate de ths of elevatlons <br /> systems bullt under pre-2008 Rules;Type IV <br /> or V systems buitt under20D8 ftules(7D80• A. eottom of dtstributbn madia H <br /> 2350 or 7080.24D0(Advanced Inspector <br /> License require� s. r�r�oa�� �wr�ceaso�waa� �.�6`��f�3or <br /> Drefnfield meets the designed vertical C. System separation y`� "� ' <br /> separation dlstanoe from periodically e <br /> saturated soil or bedrock. D. uired can iance se ratbn• a•u <br /> Any"no"answer above Jndlcates the sysiem Is •May be reduced up to 15 perceM ff allowed by Local <br /> Fa11Fng to Protect Groundwater ordinarx;e. <br /> 5. Operating Permit and Nitrogen BMP*—Compliance oomponent#5 of 5 �Not applicable <br /> Is the syetem operated under an Operatin9 Pe��� ❑Yea ❑No If"yea",A below is required <br /> IS th@ Sy3tem reqUired t0 empby a NiVogen BMP? �Yes ❑NO If"yes",B belovy[S reqUifed <br /> BMl�BestMenagementPracHoe(s)spedfre<f!n fhe system design <br /> H the answer to both questlons!s"no';thls sectlon does not need fo be completed. <br /> Com tiance crite�ia <br /> a. OperaNng Permit number: <br /> Have the 0 eratln PermR uirements been met? ❑Yes ❑No <br /> b. Is the r uired n en BMP in iace and functbni 1 Yes No <br /> Any"no"answer lndreates Noncompllance, <br /> Upgrade Requiremenffi(Mlnn.Stat§115.55)An 1mmlr�ent threat to pubNc(�eaffh end safety(lTPNS)must be upqraded,replacad,a ny use <br /> disconBrMred withln ten monU�s ol rgcelpt of this�roGos or wlfhln e ahorter perlod 1/royuFred by local or�nance.ff fhe system!s leiliny to protect <br /> gruurtd water,lhe system must be upgreded,rep/aoed,w lb use discontinued w11hln the tlme requfred by Mcal adfnance.N an exisUng sysfem <br /> (s not faUing as deflned in lew.Mrd has st least two feet ol deslgn so/l separaHon,then Ihe system need not be upgreded,�epeind,replaoed,or <br /> Ks uae WsaonNnuea;rroMdthstendlnQ arry focel orQlnance thet Js mae shkL ThJs proHslon voes not eppy fo systems!n shorelend areas, <br /> Weflhead Protection Areas,arthose used kr connecdon wr7h foal,Deverape,end lod�lny estebllshmenfs as de�ined fn law. <br /> www.pca.state.mn.us • 651•296•6300 • 800-657•3864 • TTY 651-282•5332 or 800-657•3864 • Avaltable tn altemaUve formatr <br /> wq-wwlstsf3l . }/24/12 <br />