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, Property address: 4440 Bayside Road,Orono Inspector initials/Date: JS �, 5/30/2017 (rrn►✓dd�YYYY) 4. Soil Separ�tion—Compliance component#4 af 5 Date of installation: 8/4/2004 ❑ Unknown Verificatlon method(s): �m�� Soi!o6servation does not expire.Previous soil ShorelandNVelihead protectioNFood beveraa�e �Yes � No observations by two independent pa�ties ar�sutficient, �0�� unless sife condi�ons have been altered or local Com liance crlterla: requiremenfs dii�er. For systems buitt prior to Apri11, 1996, and ❑Yes ❑ No �Conducted soil obsenration(s)(Attach tmring kk�ps) not located in Shoreland or Wellhead Protection A�ea or not serving a iood, ❑T+^ro P�''e�ous verifications(Attach bor;ng/ogs) beverege or lodging esfablishment: ❑ Not appl'�cable(Holding tsnk(s),no drainfre/d) Drainfieid has at least a two-foot vertical ❑ Unable to verify(See Comments/Fxplanation) separation distance from periodically ❑Other(See Comments�Exp/anetlon) saturated soil or bedrock. Nony�erformance systems built Apri!?, �Yes ❑ No CommernslExpianation: 1996, or lafer or for non�erfom�ance systems located ln Shoreland orWe!lhead ��ng� Protection Areas or serving a f+ood, 1-15"10yr 2/2 Loam bever�ge,or bd�ng establishmer►t.• 1&26'10 YR 4/4 Ciay Loam Drair�field has a three-foot vertical separation distance from periodically Redox�24" saturated soil or bedrodc.* Experimental; "Other", or °Performence" ❑Yes ❑ No IndiCate de hs or elevations systems built under pre-2008 Rules;Type IV or V systems built under 2008 Rules(7080. A. Boaom of dlstribution media lus 12"or more 2350 or 7080.2400 (Advan�d lnspedor License required) e, periodicall saturated soiUbedrock 24" Drainfield meets the designed vertical C. S tem ration 36"+ separation distanoe from periodically . satureted soil or bedroc�Cc. D. R utred c�m ianoe se ration* 36" Any"no"answer above lndicates the system is *May be reduced up to 15 peroent if allowed by Local failing to protect groundwater. Ordinance. 5. Operating Permit and Nitrogen BMP*—Compiiance component#5 of 5 � Not Appltcable 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 SMP=Besf Management Prectice(s)spec"ri'ied in the system design If the answer to both questJons/s "no'; th/s section does not need to be comp/eteaL Com Ifance criteria a. Operating Permit number. Have the O ratin Permit re uirements been met? ❑Yes ❑No b. Is the r uired n' en BMP in lace and ro er1 functionin ? Yes ❑No Any"no"answer indlcates Noncompllance. Upgrade Requlrements(Minn.Stat.§115.55)An immirrent threat to public heslfh end s�ety(fTPNS)must be upgreded,repfeced,orits use dlscontlnued wlthln ten months of reoeipt of fhis noHoa w wid�ln a shorter period if roqulied by bca!ond4inance.lf the syst�sm is iallfng to protect ground weter,Nte sysf�m must be upgr+adetl,replaoed,or Its use dfscwntinued within the Hme requfied by locel adinance.'If an existing system is not fafJfng as defrned!n/aw,end has at/east two feet of destgn soil separat�n,then the system need not be upgraded,repeired,replaced,or its use discondnued,notwffh�anding any bcaf ordlnanc�r that is more�ct Thts provlslon does not a�ly to systems in�lar►d aroas, We!lhead FrotectMn Areas,or those used!n conrreetion with food,bevereg�e,and lodging establishments as�flned!n Jaw. www.pca.state.mn.us • 651-296-6300 • 500-657-3864 • TT1f 651-282-5332 or 800-657-3864 • Available in altemative formats wq-wwtsts4-39 • 3/i6/12 Page 3 of 3