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Home My WebLink About2009 Septic info 10/15/2009 16: 15 9528733112 PAGE 01105 Minnesota Pollution Compliance Inspection Form Control Agency S2OLafayee Road North Existing Subsurface Sewage Treatment Systems (SSTs) St.Paul,MN 55155-4194 Instructions on pale Parcel number: For Local Tracking Purposes 1 ' / System status: %Compliant ❑ Noncompliant (based on all compliance requirements) Summary Form 1` r \ % Property Informationn� f Property owner name(s): licz'tj 5 Sa n Sl. h�pcoll Property address; am: ' / . G - -e $ 'o n_04 •dt7 4 ✓ .sio - -—. Property owner's address(if different): —"---� County*l n&p( 4 Property owner phone: Permitting authority: 6*.___ (/Y lLQ (� Date system constructed: 16190 _ Reason for inspection: .L' System Description • Brief system descrlptior(f) 0 - h �O1 cj ct l p um�, , , C�11.91 Local permit number: \ d�� '`�"-=�'--!' �---- Number of bedrooms: 5 _ Design flow rate: �� .._._ Is the system: In Shoreland area? ❑ Yes i) No In Wellhead Protection Area? � ❑ Yes I k1rNo An U.S. Environmental Protection System serving a Minnesota Department rr�� Agency (EPA) Class V Injection Well?0 Yes liO No of Heath (MDH) licensed facility? ❑ Yes Xo Compliance Status (Based on state requirements—additional local requirements may also apply.) JBased on She information gathered and reported on attached forms, the compliance status of this system is (check one) Certificate of Compliance—valid until (3 years from date of report): ❑ Notice of Noncompliance• For Noncompliant systems: The ea son for noncompliance is: Thisnoncompliant system Is classified as (check one below): ❑ Imminent threat to public health 8 safety ❑ Failing to protect ground water 0 Not in compliance with operating perm.: Certification (Completed form must be submitted to the local unit of government within 15 days.) /hereby certify that all the necessary information has been gathered fo determine the compliance status of this system r/c determination of future system performance has been nor can be made due to unknown conditions during system con sit ucaor? possible abuse of the system, inadequtste maint nonce, or future water usage. Name: ---705c Sr1IU( Certification number: R`1D5-4 Business license name and number: jcr)tL} Se l 5 rnL 5.Q ___ or Name of local unit of g er merit: Signature: Date: JOl tJ51 Required Attachments Inspector Complete: This Inspection Report is 5 pages long. Check compliance forms attached: it Hydraulic Performance air Tank Integrity applicable) 'System drawing/As-built drawingany 9 ❑ Soil Separation ❑ Operating what is re Form of ❑An assessment of local requirements that are different from is requirec on :res form x Soil Boring Logs 0 Abandonment form (If appropriate) ❑ other information (lift); • Upgrade Requirements (derived from Minn. Stet. § 115,55)An imminent threat to public health and safely(iTPNS)must be upgrade° rebiacec a • its use discontinued within Ian months of receipt of this notice or within a shorter period I/required by local ordinance.If the system is failing to protea gro..'ip water,(he System must be uppreded,replaced,or its use discontinued within the time required by local ordinance, if an existing system os nor ra,.'.rg as ca;:;-a: - raw,and has of least iwo/eel o/design soil separation.then the system need not be upgraded,repaired,replaced, or its use discontinued.noiival, ger ;:y a^. rota/ordinance mat is more strict. This provision does not apply to systems in shorelsnd areas, Wellhead Protection Areas,or Inose used.n,9n,",Qi' ,;.:...:r •„ oeverape, nd lodging establishments as defined in law, wq•wwists4.3f1 Compliance inspection Form for Exisr;ng SSTs 4/1/08 10/15/2009 16: 15 9528733112 PAGE 02105 Parcel number: --- System status: Y Compliant liant ❑ Noncompliant (as determined this form) Hydraulic Performance and Other Compliance Compliance Issue #1 of 4 Date of observation: 10 ( ILl I_01 Reason for observation: 4;1`el This form expires upon next inspection or in three years,whichever occurs first: Compliance questions/criteria: (Required) Verification Method*: (Optional) (Check the appropriate box) (Check the appropriate box) Does the system discharge sewage to the El Yes (KNo ground surface Searched for surface outlet Does the system discharge sewage to drain CIYes 14 No ® Performed hydraulic test _tile or surface waters? tlif Searched for seeping in yard Does the system cause sewage backup ❑ Yes No 0 Checked for backup in home into dwellinpi or establishment? 0 Excessive ponding in soil system(D-boxes Do other situations exist that have the ❑Yes jifklo potential to immediately and adversely ❑ Homeowner testimony impact or threaten public health or safety i Examined for surging in tank (electrical,unsafe covers,etc. ? Any"yes"answer indicates that the system is an imminent 0 "Black soil"above soil dispersal system threat to public health and safety. [] System requires"emergency'pumping C] Performed dye test Does the system pose a threat to ground ❑ Yes No water for any conditions deemed non- ❑ Other: protective as determined by the inspector? "Yes"indicates that the system is failing to protect - ground water. If"yes" describe the condition noted: --- -- 'No standard protocol exists. This list is not exhaustive, I ' in sequential order, nor does it indicate which combinations are necessary to make this determination. I Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's (MPCA) Compliance Inspection(Form for Existing Subsurface Sewage Treatment Systems- Observations, interpretations, and conclusions must be completed t y an inspector. Completed form must be submitted to the local unit of government within 15 days. Property owner name(s)C: �ill it sa to 1 s�i r fl sa n Property address: Z —� W " cII d, 553S-Co a D ro fl b�� M J� SS3S-(o Property owner's address(if different): — — County: 4:10/nTi r. Phone: I hereby certify that I personally made the observations, interpretations, and conclusions reported on this form and that they are correct. Name: 1 ealorNC) Certification number: p,1(,56r .___...._ Business license name and number: CSA ye a)uNa Spx u1t-QS EriL ..- 50 or Name of local unit of goent: Signature: Date: 10.11510C1 . .. . — • • wq-wwists4-31 Compliance Inspection Form for Existing SS TS 4/1/08 10/15/2009 16: 15 9528733112 PAGE 03/05 Parcel number: - System status: ' Compliant ❑ Noncompliant (as determined by this form) Tank Integrity and Safety Compliance Compliance Issue #2 ofq 4 r Date of observation: 10 l14 9 Reason for observation: c4i, This form expires on (three years): Compliance questions/criteria: (Required) Verification Method': (Optional) (Check the appropriate box) ,. (Check the appropriate box) Does the system consist of a seepage pit', ❑ Yes 'No 0 Probed tank bottom cesspool, drywell,or leaching,pit? Do any sewage tank(s) leak below their ❑ Yes NI No El Observed low liquid level designed operating depth? 0 Examined construction records If yes,identify which sewage gz Examined empty(pumped)tank tank leaks. ❑ Probed outside tank for"black soil" Any"yes"answer indicates that the system is failing to protect ground water. 0 Pressure/vacuum check ❑ Other: Seepage pits meeting 7080.2550 may be compliant if allowed In ordinance by local permitting authority. No standard protocol exists. This list is not exhaustive.in sequential order, nor does it indicate which combinations are necessary to make this determination. Safety Check 1. Are any maintenance hole covers damaged,cracked,or appeared to be structurally unsound? ❑ Yes' NI No 2. Were all maintenance hole covers replaced in a secured manner(e.g., all screws replaced)? Yes (] No' 3. Was secondary access restraint present(safety pan,second cover, or safety netting)-highly recommended. ❑ Yes X No 4. Was any other safety/health issue present? ❑ Yes' 04 No Explain: _ _ 'System is an imminent threat to public health and safety. Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's (MPCA) Compliance Inspection Form for Existing Subsurface Sewage Treatment Systems. Observations, interpretations,and conclusions must be completed by an Inspector, maintainer, or service provider. Completed form must be submitted to the local unit of government within 15 days, Property owner name(s): �l tel S U S'n Sotr q 5 6y�!1.., c-- - r Property address: A50 LC4r t YC1� ) ono na4 /VIN S ?5jL - -- - Property owner's address(if different); County: y`„ Phone: 1 hereby certify that I personally made the observations, interpretations, and conclusions reported on this form and that they are correct. �`� 1 Name: �t�\ �J.�' AUf\C Certification number: RIC95 Business license name and number: , \Uto (,pS In C. . 050 - or Name of local unit of governTri : .49 �l�/f I Signature: '► A �i Date: 0 wq-wwisrs4-31 Compliance Inspection Form for Existing 5STS 10/15/2009 16: 15 9528733112 PAGE 04/05 Parcefinumber: - System status:ex Compliant ❑ Noncompliant (as determined by this form) Soil Separation Compliance and Other Compliance Compliance Issue #3 of 4 Date of observation: Ai l'-I _ Reason for observation: 131[This information on this fo doe not expire, Compliance questions/criteria: (Required) Verification Method**: (Optional) „-(Check the appropriate box) (Check the appropriate box) For systems built prior to April 1, 1996, and not Sk Conducted soil observation(s) (attach boring logs) located in Shoreland or Wellhead Protection Area or not serving a food, beverage or ❑ Two previous verifications (attach boring logs) lodging establishment: ❑ Other: 1�,4 Does the system have at least a two-foot .1 _ Z la 1 L1/6 ' vertical separation distance from periodically Q i r saturated soil or bedrock? ___ X Yes 0 No NO 111 For non-performancet systems built April .1, fit 0 Vt f 4 S r\ I 1996, or later or for non-performance systems S located in Shoreland or Wellhead Protection Soil observation does not expirerevious observations Areas or serving a food, beverage or lodging by two independent parties are sufficient, unless site establishment: conditions have been altered, Does the system have a three-foot vertical separation distance from periodically saturated soil or bedrock?' [] Yes ❑ No For reduced separation distance systems (i.e., "performance"systems under old 7080.0179 or ' May be reduced by up to 15 percent if allowed in focal Type IV or V system under new 7080. 2350 or ordinance, 7080.2400): ""No standard protocol exists. This list is not exhaustive, Does the system meet the designed vertical in sequential order, nor does it indicate which separation distance from periodically saturated combinations are necessary to make this soil or bedrock?' ❑ Yes ❑ No determination. Any"no"answer indicates that the system Is failing to protect ground water. Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's (MPCA) Compliance Inspection Form for Existing Subsurface Sewage Treatment Systems. Observations, interpretations, and conclusions must be completed by an inspector or designer. Completed form must be submitted to the local unit of government within 15 days. Property owner name(s): G r_c� ` s U -in m ps o .--.. Property address: '2-e p w r LI C'PJ no.�_ Irl _ —__-• Property owner's address(if different)! County: l h.&p l ' Phone: I hereby certify that I personally made the observations, interpretations, and conclusions reported on this form and that they are correct. Name: (1 a\ur-\6 Certification number: P-.1(()_6' �((Q ' Business license name and number. SLL.2L tun 6 S.('wL2,S-.._..w� L -- or Name of local unit of gov VL L�� Signature: _ Date: _IQ - --__— wq•wwists4-31 Compliance inspection Form for xlsting SSTS ailing 10/15/2009 16:15 9528733112 PAGE 05/05 Swedlund Septic Services, Inc. 25648—200th Street • Belle Plaine, MN 56011 952-873-3292 Josh J. 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