The URL can be used to link to this page

Home My WebLink Aboutseptic info Aug 29 08 04:21 p 763-213-0699 763-213+0695 p,1 �=`.:�;r::-:. Mi�nnesota Pallution Compliance Inspection Form � Control Agency . _ 520 Lafayette Road North Existmg Subsurface Sewage Treatment Systems (SSTS) St.Paul,MNS5155-4194 Instructions on page 7 � Parcel number: �� , �� "L� For Local Tradcing Purposes: r Systern status: �Compliant ❑ Noncompliarrt (based an al!compl�a�ce requiremenls) Summary Form Property Information Property owner name(s): __��o� �GL'L'�� Propertyaddress: /:5��. (�`� � �., �� -. Properiy owners address(rf different): CouMy:�p�n�t� Property owner phone: � �� -�� O�d Permitting authority: Date system constructed: ��,� Reason for inspection: System Description Brief system description: — � S G�' ' d�1p `� .�7i .��'�G� Local peRnit number: Number oF be rooms: � Design flow ra e: ��' ��a[,__ __ Is the system: �1� In Shoreland area? ❑Yes �,No In Wellhead Protedion Area? ❑Yes [$�No An U.S. E�vironmental Protection System serving a Minnesota Departrnent Agency(EPA)Class V Injection Well?�Yes �No oi Heath(MDH)licensed facility? ❑Yes �Na COR1PIidnC@ S�tUS (8ased on state requirements-additionaf local�equirements may also apply.) Based on the informatiun gathered and reparted on attached forms,the corr�pliance status of this system is(check one�: �Certificate of Compliance-valid until (3 years from date of report): ❑Notice of Noncompliance-For Nonoompiiant systems: The reason for noncompiiance is: This noncompliant system Is classified as(check one below): ❑IrnmineM threat to public healt�&safety ❑Failing to protect ground water Q Not in compliance with operating permii C@rt1f1C8tiOl1 (Completed form must be submitted to the local unit of govemment within 15 days.) � 1 hereby certify that a/l the necessary inlormation has been gatherBd to determine the compliance sfatus of this system.No determinatlon of hrture system perfonnance has been nor can be made due to unknown conditi�ons dur+ng system corrstruction, possib/e abuse of the system, inad ate m 'ntenance, or future water usage. Name: � Certification number: ' �� Business li se narne and number: �� ,,� �'�'fC�t �2 � - or Name of local unit of government: Signature; Date: Sj.--_��—G� Required Attachments Inspector Complete:This Inspection Report is�pages long. Check compliance forms attached: �Hydraulic Performance Tank IMegrily '�Soil Separa6on ❑Opereting Permit Forrn(it applica�e) System drewing/As-built drawing ❑M assessmen o any lo�al requirements that are diFf�ent irom what is re�uired on this forrn Soi�ring Logs ❑Abandonment form(If appropriate) ❑Other iniormation(lisl): U�J�8d9 R@qUif A�I'19f1tS(derived�rom Minn. Stat. §115.55J M imminen�threat to public heetth and sa/e!y(ITP►!S)must ba�yraded,rapfaced,or i!s use d'iscarRinued wifhin tan morNNs of receip7 olth/a not�e or wiihin a aho�er perlod if required by local oidinence,H the aystem is faiNr►g to prvfecf gmund wa�r,tAe sysfem musf be up�eded,mplaced,orias use�sconfirwed wi7Nn fhe Ume required by loca!oroVnance.1!an exiafirW�g sysrom�s rrot failing as deHnad in law,and has atleasl fwo leel oldesign sal sep�araUor,,fhen fhe sysfem neeCnof be upgraded,repsirbd,replaced,o�iYs use disconGnued,ndwifhstanding any bcal ordinance iAat is mone siriol,ThFs provrsion does rwt apAly lo sysfema in ahareJend areas,WelYiead P�otecfbn Areas,orJhoae used in connecfion»vth food, beHerage,and bdging esfaWishmen�a as deRned In law. wwists4-3f tamplionce Ins,pectiai Form for Existing SSTS �108 Aug 29 08 04:21 p 763-213-0699 763-213+0695 p.2 ► ) ,� Parcel number: 1 �� W ; . � �%��'�� System status: �CompliaM ❑ Noncompliant f {as del�nnined y hrs form) Hyd�aulic Perfo�n�ance and Other Compliance Compliance lssue #t of 4 Date of observation: ��rj--G�� Reason for observaiion: , This forrt�expires upon next inspection or in ttuee years,whichever occurs firsl: Compiiance questions/criteria: (Required) Verification Method': (Optional� Check fhe a ro riate box (Check the appropriate boxJ Does the system discharge sewage to the ❑Yes � No �Searched for surtace outlet round surface? Does lhe system discharge sewage to drain ❑Yes �No � Performed hydraulic test tile or surface waiers? � Searched for seeping in yard Ooes the system cause sewage badcup ❑Yes �No � Checked for baclurp in home into dwellin or establi"shment? ❑�Excessive ponding in soil system/D-boxes Do other siWations exist lhat have the ❑Yes (�No � Homeowner testimony poteMial to imrnediately and adversely impact ot threaten public heafth or safety (� Examined tor surging in tank electrical,unsafe covers, etc. ? - �� "Black sal"above soil dispersal system Any"yes"answe�r lndicates Hrat the syslam is an immJneni throat b public health and sefety. ❑ System requires"emergency"pumping ❑ Pe�farmed dye test Does the system pose a threat to ground �Yes �No ❑ Other: waterfnr arry condilion5 deemed non- rotective as determined b 1�e ins ecto� "Yes"irtdicates that the sysfem!s failing to protect groynd water.!�"yes';describe the condltlon noted: •No standard protacol exists. This list is not exhaus6ve, in sequential order, nor does it a�dicate whkh cornbinations are necessary to make this dete�mrnation. Certification This form is to be completed and attached to the Summary Form of the Minnesata Pollution Control Agency's(MPCA)Compleance Inspection Form for Existing SubsurFace Sewage Tresbnent Systems.Observations, interpretations,and conclusions must be cornpleled by an inspector.Completed form must be submitted io the local unR of governmerrt wilhin 15 days. Properly owner name(s); I.Z�*— 1�� Property address f�'�� S� . t/ _ _ Property owner's address(if dif�erent): County: ��t�.�s7� Phone: �,.1�� -� �' ! C� !hereby certify that 1 personally made the obsenratians, interpretalions,and concl�sions r�eporfed on this form and that fhey are correct. Name: Certification number. �C> 7� / Busine license name and number: �� • �- �� s' � or Name of loca{u ' of government: , Signaiure: Date: �' --�`��- �� I wq-wwists4-31 ComplPante�nspection Fam for Existins SSTS 4J1108 Aug 29 08 04:21 p 763-213-0699 763-213+0695 p.3 � cx:, �� - �:�; Parc�l number: � � � Systern status: �Compliant ❑Noncompliant . (as detertnined by1'his iorm) Tank Integrity and Safety Compliance Compliance Issue #2 of 4 , Date of observation: � —'�-q -C,�1 Reason tor observation: This form expires on(three years): Compliance questionslcriteria: (Required) Verification Method�":(Optional) Check�he a ro riate box (Check the appropRate boxJ Does the system oonsist of a seepage pit", ❑Yes No �. Probed tank bottorn cess ol,d U or leachin it? Do any sewage iank(s)leak below their ❑Yes (�No ��rved Eow liquid level desi ned o ratin de th? ' ` �Examined construdion records If yes, ide�ify which sewage r' ❑ Examined empty(pumped)tank tank leaks. � :� � probed outside tank for"black sal" Any'�es"answ�er indrcates th the system is failJng to pro(�ect � ' ' ground water. ❑ Pressure/vacuum check � ❑ Other: ' Seepage pils meeting 70802550 may be compliant if allowed in ordinance by loca!permitting autho�iry. "No standaM protocd exJsfs. This liat Is not exhaustive,� sequential orde��pr does it fndicate whlch Combinstions are necessary to make this determinatio�, Safety Check 1. Are any maintenance hole co�rers damaged,cracked,or appeared to be sbvcturaly unsound? ❑Yes" �No 2. Were al!maintenance hole covers replaced in a secured manner(e_g.,all screws replaoed)? �Yes ❑No` 3. Was secondary access restraint present(safety pan,second cover,or safety neiting)-highly recommended. ❑Yes �No 4. Was any olher safety/heaRh issue present7 ❑Yes' �No Explain: 'System is an imminsnt threat to publlc/walth arrd safety. Certificatiort This form is to be completed and attached to 1he Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compliance Inspectlon Form for Existing SubsurFace Sewage T�eatment Sysbms.Observations, inlerpretaiions,and canclusions must be completed by an inspector,maintainer,or service provider.Completed form musi be submitted to the local unit of govemment within 15 days. � Property owner name(s): /o2C9-C� //��?�,� Property address: �,'��.7 � �. J7�:� C9�`�u�-y�.r,� Properly owner's address(f different): County: � . Phone• � l�. " �� ' I C ` I hereby certi/y that I persona►ly made the observations, inierpretations, and conclusrons reported on this fomr and that they are correcf. Name: Certificaiion number: J�' �JI � , T�'_i Business lic �se name and number: _.��7, �- ��.�(y�� yL.t� . or Name of local unit of govemment: Signalure: .� � ---------------- �ate: �-�- ��T--C��_ _ _ ` . _ wq-wwists4- 1 Complionce lnspeccion Form jo�Existing SSTS 4/fl08 Aug 29 08 04:21 p 763-213-0699 763-213+0695 p.4 Par�el number: �,�,�� A. �� System status: (�Compliant ❑Nvncompl'�ant � (as deterrnined by this Iform) Soil Separation Compliance and O#her Compliance Compliance Issue#3 of 4 , Dabe of cbseroation: ��"�� Reason iar observation: This irrforma�ion on this farm does not expire. Compliance questionslcriteria: (Required) Ve�i�cation Method"*:(Optional) Check lhe a ro ate box (Check the apprapriate 6ox) For systems built prior to April 1, 1996,and not ('� Conducted sail observation(s)(attach boring Iogs) located in Shoreland or Wellhead Protection Area or not serving a food,beverage or ❑ Two previous verifications(attach boring logs� lodging establishrnent: ❑ Othe�: Does the system have at Ieas1 a lwo-foot veNical separation distance from pe�iodically saturated sail or bedrock? Yes No For non-performance systems buittApril 1, 1996.or later or for non-performance systems Soil observation does not expire.Previous observations bcated in Shoreland or Wellhead Protection by�,�ro independent parties are sufficient,unless site Areas or serving a food, beverage or lodging conditions have been altered. establishrnent: Does the system have a three-Foot vertical separation distance from periodically saturated soil or bedrock?' Yes No For reduced separation d�stance systems(i.e., "performance"systems under old 7080.0179 or ' May be reduced by up to 15 percent i�allowied in local Type IV ar V system under�ew 708�. 2350 or or+dinance. 7080.2400): •'No standerd protoco!exists. This list is not exhaustive, Ooes the system meet the designed vertical in sequentia/ord�,nor does it lnd/cate whkh separation distance f�om periodically saturated � combinations are nec:essary to make this soil or bedrxk?` � ❑Yes ❑No determinafion. Any'�o"answrrindicates fha!the system is tailrng fo profect ground water. Certification This form is to be completed and attached to the Summary Form of the Minnesuta Pollution Control Agency's(MPCA)Compliance Inspection Form for Existing Subsu�face Sewage Treatment Systems. Observations, interpretations,ar�d condusions must be completed by an inspector or designer.Completed form must be submitted to Ihe local unit of govemment within 15 days. Property owner name{s): (J 6� �� Property address: �� 6? �v � Property owner's address(it different): �/ County: �Q./)7n�� __ Phone: ��y� •-��d`ti 1 hereby certify tha�f persona!!y made the observetions, interpretations.and conclusions reported on this torm and fhat they are correct. Name: _ 9 Certification number: _�� Business ' nse name and n�mber: ��_�� or Name of local unit of government: Signatu�e: . ..__ Dete: ._�„��-'n� — �� . .__.......— wq•wwists4-3i Complionce lnspection Fo�m for Exist�ng SSTS . 411/OS Aug 29 08 04:21 p 763-213-0699 763-213+0695 p.5 .' I �� 1�� C�r�z,�-- . Site Sketch: � : � : : :, : i r ; ' . ..�. . , .� . � � . � . . % . .. .11:�.-.� .. % . .. . ' S^ ' . .�.. •� '' . .. ' . . .�.. . . ��;�,al�. . .:. . . ' . .�....i . . 't' � Yr�� : i ' "Y . • ,'�y/�,:� „"•,...,' . .. . .. f . . .•r . .� ir�. . . .^ . �..r.+. + .' _` ` .f. ;�f. ., .; ,.;^.. .�. ��t, . ..� . .. . . .; . .�.. .� • w •l'. •�• .e . � .�. ..+. % ` . .� . . . • ` � � � ' --;•• .��. ...`.�1�� . ...�;.. _. . ...f _ ;. . �.. .+.. ; �. , • :. . . , . . ...,. � . :: . . .. . ....... . . :. ..f,..i._ . � • �• , , . ; . ° ', ; f ',' • - • • ' . .�"'�. .:. .L�. = ' •• - .' •• : • �.- ' • ' • = • ' •- - • ' • 1 ' �' a. .J. -i. .J.� �r.. ;• �• j{'�/1, .• . •r ! 1 .. 1�. J J ...7 . .',� ��j 1 J 4- • "!�/�.r�. :�. .yi..�r _.} . .� . .. -�....��. . . j... ! I �')� •� _�� . ..;.. f .`. ., . .. �'+ .r�. ��'�� 00• . . . . : . ; ._;.. . . ;..:t;��?. r .+. . � r _ : .� . ;: .. : . : ...�.. .. . : ...: ..� ._; . � a o �o' zo� . . . : � , ; . . �: ' N :: . - . � .+ : ..�... .�.. Y .�.. Y . . ..p...J.� � • . .. . . . j . f. _�.. . � i�. � . t. ..1. .' . j.• RCu� . . .. . . f. .f . . '.. ... ..1... j •r.'.. p r 1 Suggated items for site sket .Wett,well setback to rysum,dwelling o�other establishmen;taok(s),sai!ueatmeac rystem. rescn+cd soil trcatment area,curcain drain,propdry lines,watenvays,and buried lines (chose NO'C instaJled b}�the utiliry). Include sius and lengch and approximate distatices from fixed refe�rna poinu such as streets and buildings.�Plea9e attach pcevious as-built dtawings,inspeetion repor[s.Certificatc(s)o f Comp[iarsce and Tiotice(s)of NoncoRiptiance. Soil Borin;s (SB#): Locate each boring on the map above,indicate on the right of the columns •low the texture, structure,color,deptb of each different soil type, evidence of mottling;bedrock and .,nding water. Also indicate if the maEerial is fi1L SB# SB# SB# r � � C�`'�' ' , j�� ' �'�.. 3� L�G... �a.�� _�, 5�=�c' �`""�- � � Comment�� l , � � � S80 $ i �C�1' 1�,� �!e �. � � . . ,, . : �� , � � ,, � "�,., � , � . � � � . � � . � �� .,� � � � , � �� ..� � , y � r � ,� ` � ,� ,\ 'r �'!�5�' j, .*'�6 � � , � � � �l, . . , .. . , . �,r, . ..� - � �