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Property address: LAOS •0uv, l Vi t. '154 Ircc, Inspector initials/Date: ` ''�:' i— 5( 4. Soil Separation-Compliance component#4 of 5 Date of.installation: 44 - 3) -0 -% 0 Unknown Verification method(s): ShoretandWeilh ed protection1Food Beverage ❑Yes is No Soil observation does not expire.Previous soli Lodging? observations by two Independent parties are sufficient Compliance criteria: unless site conditions have been altered or local For systems built prior to April 1, 1996,and ElYes ❑No requirements differ. not located in Shoreland or Wellhead M Conducted soil observation(s)(Attach boring logs) Protection Area or not sewing a food 0 Two previous verification(Attach boring logs) beverage or lodging establishment ❑ Not applicable(tiokfing tank(s),no drainilekp Drainfield has at least a two-foot vertical 0 Unabld to verify(See Comments'Explanation) separation distance from periodically ❑ 001B1.(See ,ts/Explanallon) saturated soil or bedrock. Non-performance systems built April 1, 0 Yes 0 No Comments/Explanation: 1996,or later or for non-performance systems located in Shoreland or Wellhead Protection Areas or serving a food, beverage,or lodging establishment: Drainfield has a three-foot vertical separation distance from periodically • saturated soil or bedrock.* • -Experimenter, `Other",or Performance" ®Yes 0 No Indicate depths of 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) I,d '(`,l' 5 B. Periodically saturated soft/bedrock Drainfield meets the designed vertical • C, System separation separation distance from periodically saturated soil or bedrock. D. Required compliance separation* Any"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? 0 Yes 0 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 completed. Compliance criteria a. Operating Permit number: 0 Yes 0 No Have the Operating Permit requirements been met? b. Is the required nitrogen BMP in place and properly functioning? ❑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,or Its use discontinued within ten months of receipt of this notice or within a shorter period Ifrequired by local ordnance.if the system is falling to protect ground water,the system must be upgraded replaced or its use discontinued withkr the time required by local ordinance.if an existing system is not failing as defined in law,and has at least iwo fleet of design soil separation,then the system need not be upgraded,repaired,replaced,or its use discontinued,nom any local ordinance that is more strict.This proWslon does not apply to systems in shore and areas. Wellhead Protection Areas,or those used In connection with flood,beverage,and lodging establishments as defined in law wtiw.pca.State.mn.us • 651.2964300 • 800-657-3864 • TTY 651-282.5332 or 800.657.3864 • Available in attemative formats wq-wwlsts4 3f • 1124112