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Property Address: 18584 Troy Street NW,Elk River Inspector Initials/Date: RGP 11/30/15 4. Soil Separation-Compliance component#4 of 5 Date of Installation: (]Unknown Verification method(s): Shoreland/Wellhead protection/Food Beverage QYes ❑No Soil observation does not expire.Previous soil Lodging? observations by two independent parties are sufficient, unless site conditions have been altered or local Compliance criteria: requirements differ. For systems built prior to April 1,1996,and ❑Yes ❑No I] Conduct soil observation(s)(Attach boring logs) not located in Shoreland or Wellhead ❑ Two previous verifications(Attach boring logs) Protection Area or not serving a food, ❑ Not applicable(Holding tank(s),no drainfield) beverage or lodging establishment: ❑ Unable to verify(See Comments/Explanation) ❑ Other(See Comments/Explanation) Drainfield has at least a two-foot vertical separation distance from periodically saturated soil or bedrock. Comments/Explanation: shoreland needs 36"separation Non-performance systems built April 1, ❑Yes (]No 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.* Indicate depths of elevations "Experimental","Other",or"Performance" ❑Yes No A.Bottom of distribution media unknown systems built under pre-2008 Rules;Type IV B.Periodically saturated soil/bedrock 72"+ or V systems built under 2008 Rules(7080. C.System separation unknown 2350 or 7080.2400(Advanced Inspector D.Required compliance separation* 36" License required) *May be reduced up to 15 percent if allowed by Local Ordinance. Drainfield meets the designed vertical separation distance from periodically saturated soil or bedrock. Any"no"answer above indicates the system is Failing to Protect Groundwater. 5. Operating Permit and Nitrogen BMP*-Compliance component#5 of 5 El 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 completed. Compliance criteria a. Operating Permit number: ❑Yes ❑ No Have the Operating Permit requirements been met? b. Is the required nitrogen BMP in place and properly functioning? Oyes ❑ No Any"no"answer indicates Noncompliance. Upgrade Requirements(Minn.Stat.§115.55)An imminent threat to public health and safety(ITPHS)must beupgraded,replaced, or its use discontinued within 10 months of receipt of this notice or within a shorter perior if required by local ordinance.If the system is failing to protect ground water,the system must be upgraded,replaced,or its use discontinued within the time required by local 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. 651.296.6300 800.657.3864 www.pca.state.mn.us TTY 651.282.5332 or Available in alternative formats wq-wwists4-31 1/24/12 800.657.3864 6