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Home My WebLink AboutCompliance Inspection Form for Individual Sewage FROM 4 RYS PHONE NO. : 4422091 Mar. 13 2005 08:43PM P1 2/25/02 Water/Wastewater-ISTS4.31 Compliance Inspection Form for Existing -mss Individual Sewage Treatment Systems Minnesota nnesr ti lllution Agency Completion of this form fuflls the minimal requirements of Minn, Stat. § 115.55(2001)and Minnesota R. ch. 7080(1999). Please refer to local ordinances for other requirements or information,especially for compliance requirements for bedroom additions. General: Date of Inspection: Reason for inspection: �0AN /11F/2i ce Property Owners) de;7v 'Telephone Person requesting inspectionTelephone( ) Site Address -3L f-9— city Zip Code^-clzi Fire No./ Parcel No. County Township Legal Description / / Local Regulatory Authority�l ec/ T Date system constructed `�" q8 System in Shoreland Area: yes�no System in Wellhead Protection Area: yes-6 System serving a MDH licensed facility: ye no Local Permit* (if any) Systems built prior to April 1, 1996 and not located in Systems located in Shoreland or Wellhead Protection Shoreland or Wellhead Protection Area or Serving a Food, Areas or Serving a Food, Beverage or Lodging Beverage or Lodging Establishment Establishment, or systems Built after March 31 1996 Is the system an imminent threat to public health or Ys the system an imminent threat to Public health safjW. (ayes answer is an 17PHS system) or safety? (a yes answer is an 17PHS system) Discharge of sewage to the ground surface? YES NO -Discharge of sewage to the ground surface? YES 0 -Discharge of sewage to draintile or surface waters? YES NO -Discharge of sewage to draintile or surface wagers?YES NO -Sewage backup into dwelling? YES NO -Sewage backup into dwelling? YES -Situation with the potential to immediately and -Situation with the potential to immediately and adversely impact or threaten public health or adversely impact or threaten public health or safety/? YES NO safety? YES NO Is the system failing? (a yes answer is a failing system) Is the system failing? (a yes answer is a failing system) -Less than TWO feet of vertical separation between -Less than THREE feet of vertical separation between system bottom and saturated soil or bedrock? YES NO system bottom and saturated soil or bedrock? YES 0 -A seepage pit,cesspool,drywell,or leaching pit? YES NO -A seepage pit, cesspool,drywell, or leaching pit? YES Is the system non-compliant? Is the system non-compliant? - Is the system regulated under a monitoring plan or - Is the system regulated under a monitoring plan or operating permit? (if no,go to page 2) YES NO operating permit? (if no,go to page 2) If yes, If yes, -Has the required monitoring taken place? YES NO -Has the required monitoring taken place? N (lf no, the system is non-complying) (If no,the system is non-complying) -Does the monitoring indicate that the system meets - Does the monitoring indicate that the system meets performance expectations? YES NO performance expectations? (If.no, the system is non-complying) (If no, the system is non-complying) Paqe 1 of 2 wa-vvwists4.31 FROM i, RYS PHONE NO. : 4422091 Mar. 13 2005 08:43PM P2 Property Owner(s) Fire No./ Parcel No. S ste m o en (Please descri the system components and attach site sketch showing system locatron): / ��ads wereused tom a the determinations for the complianceinspection?(Note_No standard protocol exists: The fol%wing list&not exhaustire, or in sequential order nor indicates which combinations may necessary to make a daterminadon) Wtro ght tanks) Hyd ulic Functioning Ve I SeparationDistance ed tank bottom Sear for surface outlet Conducted soil borings O rved low liquid level ❑ P o d hydraulic test Z:edrecords limiting layer�i✓ Ermined const records rched for seeping in yard system bottom Exalt mined empty(pumped)tank Chec for back-up in home Pr Ibed outside tank for"black soil" ❑ essive ponding in soil system/D-boxes Cl LGLl Limiting Layer Verh1cation Pressu acuum check Homeowner testimony ❑ Other Other Avg'!��L� O Examined for surging in tank &'0-/7Ae_x ❑ "Black soil"above soil system C3 Other s of the stem B sed on the compliance criteria,the system status is: (check one) ❑ failing (top ect groundwater) ❑ an i minent threat to public health or safety(ITPHS), ❑ n mpliant(monitoring issue) compliant(none of the 3 p ious conditions). Therefore;this document is a: Ce"to of Compliance 103tike of Noncompliance I this system an EPA Class V Injection Well? es no C 'fi Lon I ereby certify as a state of Minnesota licensed Inspector and/or Designer I or Qualified Employee Inspector and/or Quailfled Employee D 'gner j that I conducted an investigation that accurately determined the compliance status of this system and that my recorded ot Servations are accurate as of this date. No determination of future hydraulic performance has been nor can be made due to ur known conditions during system construction, abuse of the system, inadequate maintenance,or future water usage. Inspector's name(print) JEFF SWEDLUND Phone -� License and/orRftistration Number 398 Address '5C Er ploYed by �[l v % , Address Signature 9 Date wade R ire is fder/ved from Minnesota Statutes§115.55) ITPHS must be upgraded, nepiaced,or its use discontinued within ten months of receipt of this notice or rWffi/n a shorter pvW if rewired by local oM/nance. If the system fails to provide sufflmnt groundwater proton, then the system must be upgraded, r�/a�ced, or les use d1scontlnued within the tame required by rule or the local ordinance. If an existing system is not faN/ng as de�ii�ed in lad,and has at least trvo feet of design sal separadon, then the system need not be upgraded, repaired,repbwd,or its use di condnued,notwfibstanding any local ord1nance that is more str/ct. This does not apply to systems in shore/and areas, wellhead prfinebon areas,or those used in connection with food,beverage,and lodging establlshmenh;as defined/n law. Suaaested Attachments 1) Site sketch could also include:well,well setback to system,dwelling or other buildings,tank(s),reserved soil treatment area, surface water and soil boring locations. Include as-built drawing if available. 2) Soil boring logs,showing each horizon. Indicate the texture,color,redoximorphic features depth to bedrock,standing water and whether the material is fill. 3) A list of any and all requirements of the local ordinance that are different from the state requirements referred to on this form. 4) A homeowner survey of system performance, signed by the homeowner as being factual. S)' Monitoring data as appropriate. n.,..., FROM RYS PHONE NO. 4422091 Mar. 13 2005 08:44PM P3 Site Sketch: — J ... ? . ' r. + .. ..'f.. ..',... .. ...fir. . �... . .r. J f r ... .a. . .. .. .. .. .. r .. .. r J .. ..r... .. ..r... .. r -. . ..r... ...J.. • r� .. .. ' .. + .. .. .. r... :.. J.... . .. ..i... .. II �..�.. �' ..1... .. r .. ..leer .. .. ..+... �. .... • J ; f : � .f r. ... J J. f J• ; •? 1 .Jr..•r J.r ..r... .. • .. .. ...f.. J J ..J.. .. • J.t�..• ..+. ~Y....�I.. ! ..J... .. :. .• .. � r I ..rel.. C e--77 J r r• ; r +. r J. //,1 r• r- .... f...k�... l?/....� ..rf.. + ... .. ..............�. ;, i. ..ti. . ' ' 100, ....J. ., .. ' . i. J .. .r .;. 10' 20' ............ • r J i . I 1 J + u + rf .. .. ...I,....+...�... ..+....',.. .. .. .. 'I .. r. .�... .. .. ..�... . . . r Please indicate the location oh Well,well setback to system,dwelling or other establishment,tank(s)•soil treatment system, reserved soil Iceatment arca,curtain drain,propetty lines,waterways,and buried lints (those NOT installed by the utility). Include seizes and length turd approximate distances from fixed reference points such as streets and buildings. please attach as- built drainns,inspection reports,Cesiificat(s)of Compliance and Noticc(s)ofNoncomplianm if al-•ailable. a t Soil Borings,(BR#�: Locate each boring on t he map s bove i mdxcate on the right of the column the soil texture,structure, color, depth of each different soil type, evident of mottling,bedrock and stmiding water. Also indicate if the material is fill. jBR# ! BR# BR# BR# BR# BR# � m 0 L; w d � i RT.CORI)DEPTH OF MOTTLING,SEASONAL.I11C.14t WATER OR BFMROCKON AZOVE LTNGS Cninment�• _, What needs to be completed To bring the above system into compliance if found not in compliance? NO ,4%tea r FROM S PHONE NO. 4422091 Mar. 13 2005 08:45PM P4 M2r-11-2003 09!49am From-CIT'f OF ORMO +9522494616 T-696 ?.0031003 F-739 i lair f 32, r29 f i 1,73 p'170t�V1� Jr� 3 2/25/02 Water/Wastewater-ISTS4.31 A. Compliance Inspection Form for Existing Minnesota Pollution Individual Sewage Treatment Systems Control Agency Completion of this form fulfills the minimal requirements of Minn. Stat. § 115.55(2001)and Minnesota R. ch. 7080(1999). Please refer to local ordinances for other requirements or information,especially for com liance requirements for bedroom additions. General: I Date of inspection: '0 Reason fo Inspection: . Property Owner(s) I'al A telephone (ISA Person requesting inspection Telephone ( ) -- Site Address City jorF%io Zip Code Fire No./ Parcel No. County ✓1 i oe if`- Township Legal Desorption Local Regulatory Authority C-� Date system constructed ITi System in Shoreland Area: yes System in Wellhead Protection Area: yes(D System serving a MDH licensed facility: yesn Local Permit # (if any) Systems built prior to April 1, 1996 and not located in Systems located in Shoreland or Wellhead Protection Shoreland or Wellhead Protection Area or Serving a Food, Areas or Serving a Food, Beverage or Lodging Beverage or Lodging Establishment Establishment, or systems Built after March 31 1996 is the system an imminent threat to public health or is the system an imminent threat to public health safety? (ayes answer is an ITPHS system) sae (a yes answer is an 17PHS system) ES -Discharge of sewage to the ground surface? YES NO - Discharge of sewage to the ground surface? YE -Discharge of sewage to draintile or surface waters? YES NO -Discharge of sewage to draintile or surface waters?YES 0 -Sewage backup into dwelling? YES NO -Sewage backup into dwelling? YES -Situation with the potential to immediately and -Situation with the potential to immediately and adversely impact or threaten public health or adversely impact or threaten public health or safety? YES NO safety? YES Is the system failing? (a yes answer is a failing system) is the system failing? (a yes answer is a failing system) -Less than TWO feet of vertical separation between -Less than THREE feet of vertical separation between system bottom and saturated soil or bedrock? YES NO system bottom and saturated soil or bedrock? YES -A seepage pit,cesspool,drywell, or leaching pit? YES NO -A seepage pit,cesspool, drywell, or leaching pit? YES Is the system non-compliant? Is the system non-compliant? - Is the system regulated under a monitoring plan or - Is the system regulated under a monitoring plan or operating permit? (if no, go to page 2) YES NO operating permit? (if no,go to page 2) YES NO If yes, If yes, Has the required monitoring taken place? YES NO - Has the required monitoring taken place? YES NO (If no, the system is non-complying) (If no, the system is non-complying) - Does the monitoring indicate that the system meets - Does the monitoring indicate that the system meets performance expectations? YES NO performance expectations? YES NO (If no, the system is non-complying) (if no, the system is non-complying) Page 1 of 2 wq-wwist54.31 T -d 262E-ELB (ass) punTpamS 4sor d82 :20 BO 20 Jew Property Owner(s) Fire Nod Parcel No. _..................__.. .__.._..-..._..__-.v System Components (Please describe the system components and attach site sketch showing system location): vmCa%+ �'C- Yv S 50:�Ar - S� i i L&LD A-nill,LC What methods were used to make the determinations for the compliance Inspection?(Note:No standard protocol exists The following list is not exhaustive, or In sequential order nor indicates which combinations may necessary to make a determination) Watertighttank(s) Hydraulic Functioning Vertical Separation Distance Probed tank bottom Searched for surface outlet ❑ Conducted soil borings limiting to Depthlayer ❑ Observed low liquid level ❑ Performed hydraulic test De P 9 Examined const. records �<Searched for seeping in yard Depth to system bottom ❑ Examined empty(pumped)tank ❑ Checked for back-up in home rx- Examined records ❑ Probed outside tank for"black soil" ❑ Excessive ponding in soil system/D-boxes ❑ LGU Limiting Layer Verification ❑ Pressure/vacuum check -Homeowner testimony ❑ Other ❑ Other ❑ Examined for surging in tank ❑ "Black soil"above soil system ❑ Other Status of the system - Based on the compliance criteria,the system status is: (check one) ❑ failing (tq protect groundwater) O an imminent threat to public health or safety (ITPHS), ❑ n n-compliant(monitoring Issue) compliant(none of the 3 previous conditions). Therefore,this document is a:)<Ce ficate of Compliance 13Notice of Noncompliance Is this system an EPA Class V Injection Well? ❑ yes Vk no Certification I hereby certify as a state of Minnesota licensed Inspector and/or Designer I or Qualified Employee Inspector and/or Qualified Employee Designer I that I conducted an investigation that accurately determined the compliance status of this system and that my recorded observations are accurate as of this date. No determination of future hydraulic performance has been nor can be made due to unknown conditions during system construction, abuse of the system,inadequate maintenance,or future water usage. Inspector's name(print) JOSH SWEDLUND Phone - 1 J39 9 2- License and/or Registration Number 2502 Address r l Employed by jce SNC• Address G Signature Date a Ungrad Requirements rderivedfrom Minnesota Statutes 115.55> An ITPHS must be upgraded, replaced,or its use discontinued within ten months of receipt of this notice or within a shorter period if required by local ordinance. If the system falls to provide sufficient groundwater protection, then the system must be upgraded, replaced, or it use discontinued within the time required by rule or the local ordinance. If an existing system/s 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 does not apply to systems in shore/and areas, wellhead protection areas, or those used in connection with food, beverage,and lodging establishments as defined in law. Suggested Attachments 1) Site sketch could also include: well,well setback to system, dwelling or other buildings,tank(s),reserved soil treatment area, surface water and soil boring locations. Include as-built drawing if available. 2) Soil boring logs,showing each horizon. Indicate the texture, color,redoximorphic features depth to bedrock,standing water and whether the material is fill. 3) A list of any and all requirements of the local ordinance that are different from the state requirements referred to on this form. 4) A homeowner survey of system performance, signed by the homeowner as being factual. 5) Monitoring data as appropriate. Page 2 of 2 2 '01 2626-6GB (2913) punlpamg ysoC 0162 :20 130 20 JeW Site.Sketch: ;....>.. .. .. . ... ............ .. .......... ......... ...,. .. .. . ' .. :. ... r... r .�..';.. . , .. 100' �... 10' 20' w. .. .. N Wei 0 ' Picase indicate the location of. Well,well setback to system,dwelling or other establishment,tank(s).soil treatment system, reserved soil treatment arca,curtain drain,property lines,waterways,and buried lines (those NOT installed by the utility). Include saes and length and approximate distances froth freed reference pointe such as streets and buildings. Please attach as- built drawings,inspection reports•,Certifteat(s)of Compliance and Notice(s)of Noncompliance,if ahailable. Soil Burings (BR#E): Locate each boring on the map above, indicate on the right of the column the soil texture, structure, color, depth of each differcni soil type, evidence of mottling, bedrock and standing water. Also indicate if the material is fill. BR# BR# BR# BR# BR#. BR# K RECORD DEPTH OF A,IOTTLING,SEASONAL HIGH WATER OR BEDROCKON ADOVE LINES cnmments• What needs to be completed to briob the above system into Compli'mcc irfound not in compliance? E 'd Z6ZE—EGB (ZS6l punjpamS VsoC 6162 :20 BO 20 Jew • O X4 WPM 1021. O ✓ .` / 10 P e v 12'ph. B'Phe ' Is,phe �1 296 'Abb Ie^ to, p ph 12'm e I 1 � _ Q: XI I ,`�per \ 4•mom° Jo'� '004 to /' 16-ph° 14'phe Jo'osy 10 .2 X 1016.63 t 3.70 14' appie\ .��Ci \ X 160'93 'X01 I 14 '� �► 49 Vis. 1p��14'mgds; 101 .4 1 OB _ 4 49 A er/e \ blt , ft70 �e /X 997.76 dry o � S X996.93 shedFF Vev .�, \� 62 1001. 7 0 _d • \\� d7f o � �j� �004. i 6 � \ o 3.64 X 994.33 -} +� ----refoinin wall shed rn /� 'Al 107.39 �/- _r M ' / X 993.26 u /�'988.g9 CITYof ORONO i , Municipal Offices Street Address: Mailing Address: l9 E3I 4� :: 2750 Kelley Parkway P.O. Box 66 Orono, MN 55356 Crystal Bay, MN 55323-0066 To: The Current Owner of Address _76 5 S l.,J City Ordinance requires that onsite sewage treatment systems in Orono be inspected on a periodic basis. The onsite sewage treatment system at the above address has been inspected and the following is known about the system. A sketch of the known components of the system is available for most properties at the Orono City Hall. Imminent Public Health Threat Yes No If yes,please contact the Onsite Systems Manager at 952-249-4626 within 10 days of receipt of this notice. The septic system must be brought into compliance within 90 days. Failure to do so will result in referral to the City Attorney for legal action. System Identified as Non-Compliant Yes No If yes, system must be brought into compliance by: December 31, 2007 December 31, 2010 Other Septic Tank(s) Pump out Needed Yes No The City recommends the septic tank(s) and/or lift tank be serviced and pumped out every three years. City records indicate the tank(s) were last pumped out on --I 4_0 - . The tank(s) should be cleaned through the manhole and not through the inspection pipes,this allows for proper cleaning. Comments: Inspector: Date of Inspection Telephone(952)249-4600 • Fax(952)249-4616 www.ci.orono.mn.us o �_ , o CITY of ORONO r " i titi MunWpai Offices . �G Street Address: Mailing Address: ' ygHO�` 2150 Kelley Parkway P.O. Box 66 Orono, MN 55356 Crystal Bay, MN 55323-0066 TO Current Owner: Address: City Ordinance 199 requires that each existing on-site sewage treatment system in Orono be inspected every two years. The on-site sewage treatment system at the above address has been inspected and appears to fall into the categories checked below. SYSTEM CONFORMITY (1-3): 1 "CODE SYSTEM"An ISTS which meets all the location,design and construction standards of the current Orono Municipal Code. 2 "COMPLIANT SYSTEM" An ISTS which does not meet all the location,design and construction standards of the current Orono Municipal Code but does meet the three foot separation requirement or two foot requirement for systems installed 1996 or earlier,and which is not failing or an imminent threat to public health or safety. 3 "NON-COMPLIANT SYSTEM" A prohibited ISTS;an ISTS located within a designated 100-year flood plain,any ISTS which may or may not meet all the location,design,or construction standards of the current Orono Municipal Code and which is failing for any reason;and any ISTS with less than three feet of unsaturated soil or sand between the distribution device and the limiting soil characteristics. TANK CONDITION(5-7): Tank inspection indicates: Pumpout not needed at this time. 6 Septic tanks must be pumped out this year (city code requires tanks to be pumped out once every 3 years. Tank was last pumped ). Make sure septic tanks are pumped through manhole and not through white inspection pipes This allows for the proper cleaning. Keep water softner and iron filter discharge out of septic svUem. 7 Inspection risers missing-tanks could not be inspected. Inspection risers(4"dia.pipe)must be installed in each tank. If tanks have not been pumped out within the last three years,they should be pumped out now. DRAINFIELD CONDITION(8-10): 8 Dndnfield is dry,no surfacing evident. 9 Some evidence of surfacing,not critical yet. 10 Drainfield is saturated and visibly discharging untreated effluent to the surface. Contact the City Inspector immediately.Repairs must be completed within 90 days. COMMENTS: r�ov� 606 ok- PUP 4- 3 Date of Inspection Matt Bolterman- Septic System Inspector Note:In the event*at"impaction report is used to satisfy the requirements for a mortgage or other transfer of property,be advised that this report does notgaarantee or ontify dug an existing symm will continue to function properly,but is merely an opinion of the adequacy ofthe system under current conditions based an the avaitahl e idornmEian. Tdephone(952)24946M • Fax(952)249-4616 www d orono minus O O O CITY of ORONO Municipal Offices Street Address: MallInS Address: y+gg04' 2150 Kelley Parkway P.O. Box 66 Orono, MN 55356 Crystal Bay, MN 55323-0066 Owner: 5&r\ Me f tA4, Address: _MS w1;,hr , tower City Ordinance 199 requires that each existing on-site sewage treatment system in Orono be inspected every two years. The on-site sewage treatment system at the above address has been inspected and appears to fall into the categories checked below. SYSTEM CONFORMITY (1-3)- 1 1 "'CODE SYSTEM" An ISTS which meets all the location,design and construction standards ofthe current Orono Municipal Code. COMPLIANT SYSTEM" An ISTS which does not meet all the location,design and construction standards ofthe current Orono Municipal Code but does meet the three foot separationrequirement,and which isnot failing or an imminent threat to public health or safety. 3 "NON-COMPLIANT SYSTEM" A prohibited ISTS;an ISTS located within a designated 100-year flood plain,any ISTS which may or may not meet all the location,design,or construction standards ofthe current Orono Municipal Code and which is failing for any reason;and any ISTS with less than three feet of unsaturated soil or sand between the distribution device and the limiting soil characteristics. TANK CONDITION(5-10) ro Tank inspection indicates: 5 Pur pout not needed at this time. Tank must be pumped out this year (city code requires tanks to be pumped out every 3 years. Tank was last pumped 7 Solids accumulation in tanks is at a critical a critical level. Tanks should be pumped out as soon as possible. 8 System is discharging to the surface. Tanks must be pumped out within 48 hours to eliminate surface discharge. 9 Inspection risers missing-tanks could not be inspected Inspection risers(4"dia.pipe)must be installed in each tank at next pumpout If tanks have not been pumped out within the last three years,they should be pumped out now. 10 Inspection pipe is located directly over tank baffle(does not give accurate measurement of solids accumulation). If tanks have not been pumped out within the last three years,they should be pumped out now. D IELD CONDITION 11-14 : k\ 1 Dramfineld is dry,no surfacing evident 12 Some evidence of surfacing,not critical yet 13 Drainfreld is saturated and visibly discharging untreated effluent to the surface. Contact the City Inspector immediately.Repairs must be completed within 90 days. 14 Drainfield extent and condition unknown COMMENTS: 5-45+tc, \opkS O« P2 }"'IK nex►- 5 pc ra \`-1—O\ .w... Date of Inspection Septic System Inspector Note: In the event that this inspection report is used to satisfy the requirements for a mortgage or other transfer of property,be advised that this report does not guarantee or certify that an existing system will continue to function properly,but is merely an opinion of the adequacy of the system under current conditions based on the available information