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May. 14. 2012 12: 39PM No. 0472 P. 5 <br /> • <br /> Property address: 4 4p prq t y�<z�, 'A' 4f' Inspector Initials/Date: 4-i -a of 2, <br /> 4. Soil Separation-Compliance component#4 of 5 <br /> Date of installation: �-4 - 5� ❑Unknown Verification method(s): <br /> rrdlwelihead protectlorrlFood Beverage <br /> Lodging? 0 Yes II No Soil observation does not expire. Previous soil <br /> observations by two independent patties we sufficient, <br /> Compliance criteria: unless site conditions have been altered or local <br /> For systems built prior to April1, 1996, and Yes 0 No requirements differ. <br /> not located In Shoreland or Wellhead '7' Conducted soil observation(s)(Attach boring bpi' <br /> Protection Area ornot serving a food, ❑ Two previous verifications(Attach boring <br /> beverage or lodging establishment: MIK<to <br /> El Not applicable(Holding tank(s),no drelnileM) <br /> S�-C'�r��i'��lti W`,�,1 <br /> Drainfield has at least a two-foot vertical 0 Unable to verify(See Cornments/irplanation) <br /> separation distance from periodically <br /> saturated soil or bedrock. ❑ Other(See Comments Explanation) <br /> Non-performance systems built April 1. 0 Yes ❑No Comments/Explanation: <br /> 1996,or later or for non-performance <br /> systems located in Shoreland or Wellhead <br /> Protection Areas or serving a food, <br /> beverage, or lodging establishment: <br /> Drainfield has a three-foot vertical <br /> separation distance from periodically <br /> saturated soil or bedrock.* <br /> 'Experimental', °Other, or 'Perfommance" 0 Yes ❑No Indicate depths of elevations <br /> systems built under pre-2008 Rules;Type IV <br /> or V systems built under2008 Rules(7080. A. Bottom of distribution media q ( t n.., ifit rjF!s <br /> 2350 or 7080.2400 (Advanced inspector <br /> License required) t <br /> B. Periodically saturated soillbedrodc 3.0 $uI <br /> Drainfield meets the designed vertical , <br /> separation distance from periodically don 3.d <br /> saturated soil or bedrock. D. Required compliance separation' 'U <br /> Any"no"answer above Indicates the system is *May be reduced up to 15 percent if allowed by Local <br /> Falling to Protect Groundwater. Ordinance. <br /> 5. Operating Permit and Nitrogen BMP*-Compliance component#5 of 5 a Not applicable <br /> Is the system operated under an Operating Permit? 0 Yes 0 No If"yes",A below is required <br /> Is the system required to employ a Nitrogen BMP? 0 Yes 0 No If"yes",B below Is required <br /> BMP6Beat Management Prrrclice(s)specified In the system design <br /> Ifthe answer to both questions Is"no", this section does not need to be completed. <br /> Compliance criteria <br /> a. Operating Permit number; <br /> - Have the Operating Permit requirements been met? ❑Yes ❑No <br /> b. Is the required nitrogen BMP in place and properly functioning? ❑Yes 0 No <br /> Any"no"answer indicates Noncompliance. <br /> Upgrade Requirements(Minn.Stet§115,55)An imminent threat tc public health and safety(ITP.HS)must be upgraded replaced,or its use <br /> discontinued wlthlnten months of receipt of this notice or within a shorter period if required by local ordinance.If the system is fame to protect <br /> ground water,the system must be upgraded,replaced,alta use discontinued within the flaw required by local ordinance.if an existing system <br /> is not falling as defined in law,and has at least two Beet of design soil separation,then the system need not be upgraded,repaired,replaced,or <br /> as use discontinued,nottorMrstanding any lice/ordinance that is more Mitt This provision does not apply to systems in shoreland areae <br /> Wellhead Protection Areas,or those used in connection Oh food,beverage,and lodging establishments as defined In law <br /> WUNJ Ks ctslo mn.,e - LCA int L9nei <br /> n u...�.... <br />