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Property address: 333 Hollender Road Inspector initials/Date: RLP � 6/26/2015 (mMdd/yyyy) 4. Soil Separation—Compliance component#4 of 5 Date of installation: 6/26/2015 ❑ Unknown Verification method(s): (mm/dd/YYYY) ShorelandNVellhead protection/Food beverage Soil obse�vation does not expire. Previous soil lodging� ❑Yes � No observations by two independent parties ar�su�cient, unless site conditions have been altered orlocal Com liance criteria: r�quirements differ. For systems built prior to April 1, 1996, and ❑Yes ❑ No ❑ Conducted soil observation(s)(Attach boring logs) not located in Shoreland or Wellhead Protection Area or not serving a food, ❑Two previous verifications(Attach boring logs) beverage or lodging establishment: ❑ Not applicable(Ho/ding tank(s),no drainfield) Drainfield has at least a two-foot vertical ❑ Unable to verify(See Comments/Explanation) separation distance from periodically ❑ Other(See Comments/Explanation) saturated soil or bedrock. Non-performance systems built April 1, ❑Yes ❑ No Comments/Explanation: 1996, or later or for non-performance systems located in Shoreland or Wellhead New System Protection Areas orserving a food, beverage, or lodging establishment: Drainfield has a three-foot vertical separation distance from periodically saturated soil or bedrock." "Experimental'; "Other'; or `Performance" ❑Yes ❑ No IndiCate de ths o�elevations systems built under pre-2008 Rules; Type IV or V systems built under 2008 Rules(7080. A. Bottom of distribution media 2350 or 7080.2400 (Advanced Inspector LiCense required) B. Periodicall saturated soil/bedrock Drainfield meets the designed vertical C. S stem se aration separation distance from periodically saturated soil or bedrock. D. Re uired com liance se aration� Ally "no"answer above indicates the system is "May be reduced up to 15 percent if allowed by Local failing to protect groundwater. Ordinance. 5. Operating Permit and Nitrogen BMP*—Compliance component#5 of 5 � Not applicable Is the system operated under an Operating Permit? ❑Yes ❑ No If"yes",A below is required Is the system required to employ a Nitrogen BMP? ❑Yes ❑ No If"yes", B below is required BMP=Best Management Practice(s)specified in the system design If the answer to both questions is "no'; this section does not need to be comp/eted. Com liance criteria a. Operating Permit number: � Have the O eratin Permit re uirements been met? ❑Yes ❑ No b. Is the re uired nitro en BMP in lace and ro erl functionin ? ❑Yes ❑ No Any "no"answer indicates Noncompliance. Upgrade Requirements(Minn. Stat.§115.55)An imminent threat to public health and safety(ITPHS)must be upgraded,replaced,orits use discontinued within ten months of receipt of this notice or within a shorter period if required by local ordinance./f the system is fai/ing to protect ground water, the system must be upgraded,replaced, or its use discontinued within the time required by/ocal ordinance. If an existing system is not failing as defined in law,and has at least two feet of design soil separation, then the system need not be upgraded,repaired,replaced, or its use discontinued,notwithstanding any local ordinance that is more strict. This provision does not apply to systems in shoreland areas, Wellhead Protection Areas,or those used in connection with food,beverage,and lodging establishments as defined in law. www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in altemative formats wq-wwists4-31b • 6/4/14 Page 3 of 3