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Home My WebLink About2009 - MPCA compliance inspection form lillW a ;. Minnesota Pollution µ control Agency Compliance Inspection Form 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems (SSTS) St.Paul,MN 55155-4194 Parcel number For Local Tracking Purposes: System status: Compliant ❑ Noncompliant (based on all co pliance requirements) Summary Form L ,.... Property Information � Property owner name(s): Property address: a QQ Property owner's address (if different): County: 144 4/40, Property owner phone: 9� ' Permitting authority: •QQ,r�-o Date system constructed: 7 / Reason for inspection: 5-R!, System Description Brief system description: S`C/I T,L �,�1� a9V r.A y74'64#A7-0 ,/< .L 4 `o Kr•0R N� Local permit number: / ! / •�/�bt� / '/� Number of bedrooms: Design flow rate: (�_a Is the system: In Shoreland area? ❑Yes ErNo In Wellhead Protection Area? ❑Yes dNo An U.S. Environmental Protection System serving a Minnesota Department (t7 No Agency(EPA) Class V Injection Well?❑ Yes L� of Heath (MDH) licensed facility? ❑Yes No Compliance Status (Based on state requirements-additional local requirements may also apply.) Based on the 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 reason for noncompliance is: This noncompliant system is classified as (check one below): ❑ Imminent threat to public health &safety ❑Failing to protect ground water ❑ Not in compliance with operating permit Certification (Completed form must be submitted to the local unit of government within 15 days.) I hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No determination of future system performance has been nor can be made due to unknown conditions during system construction, possible abuse_of the system, inadequate maintenance, or future water usage. Name: �o`j<.�� k�fist/ ��j • - Certification number: fo Business license name and number: 24 [ �+ q Name of local unit of 1overnment: _- Signature: 1_. q Date: (iZ/g� l Required Attachments _ ---_ Inspector Complete: This Inspection Report is '- pages long. Check compliance forms attached: YJ Hydraulic PerformanceP 9 applicable DTank Integrity Soil Separation .Operating Permit Form(if ❑System drawing/As-built drawing ❑An assessment of any local requirements that are different from what is required on this form Soil Boring Logs QAbandonment form(if appropriate) 0 Other information(list): Upgrade Requirements (derived from Minn. Stat.§115.55)An imminent threat to public health and safety(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 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. w-wwists4-31 /1/08 •Compliance Inspection Form for Existing SSTS Parcel number: System status: Compliant p ❑Noncompliant (as determined his form) Soil Separati<.;n Compliance and Other Compliance Compliance Issue #3 of 4 Date of observation: O Reason for observation: This information on this form does not expire. Compliance questions/criteria: (Required) Check the a..ro.riate box Verification Method**: (Optional) For systems built prior to April 1, 1996, and not (Check the appropriate box) Conducted soil observation(s) (attach boring logs) located in Shoreland or Wellhead Protection Area or not serving a food, beverage or • lodging establishment: ❑ Two previous verifications (attach boring logs) Does the system have at least a two-foot ❑ Other: . Air.,- �� • vertical separation distance from periodically R£ Y A� a2r7 Y saturated soil or bedrock? ❑ Yes ❑No For non-performance systems built April 1, 1996,or later or for non-performance systems Soil observation does not expire. Previous observations located in Shoreland or Wellhead Protection 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?* &1 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 local Type IV or V system under new 7080. 2350 or 7080.2400): ordinance. **No standard protocol exists. This list is not exhaustive, Does the system meet the designed vertical separation distance from periodically saturated in sequential order, nor does it indicate which soil or bedrock?* combinations are necessary to make this ❑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): Property address: c�i p-O . C., Property owner's address (if different): County: Phone: /hereby certify that I personally made the observations, interpretations, and conclusions reported on this form and that they are correct. / Name: 14*-A.Ar✓ •1a. dr-AL-d Certification number: 7'S Business license name and number: 4 Name of local unit oi`government: r1 °P Signature: .� 1.� Date: wq-wwists4-31 1/1/08 Compliance Inspection Form for Existing SSTS Parcel number: System status: KCompliant ❑ Noncompliant (as determined by this form) Hydraulic Performance and Other Compliance Compliance Issue #1 of 4 Date of observation: o Reason for observation: S This form expires upon next inspection or in three years,whichever occurs first: Compliance questions/criteria: (Required) Check the a..ro.riate box Verification Method*: (Optional) (Check the appropriate box) ❑ YesN Does the system discharge sewage to the .round surface? o ( Searched for surface outlet • Does the system discharge sewage to drain ❑Yes jNo Ci Performed hydraulic test tile or surface waters? kSearched for seeping in yard Does the system cause sewage backup ❑ Yes V, No into dwellinq or establishment? r ❑ Checked for backup in home Do other situations exist that have the CI Excessive ponding in soil system/D-boxes potential to immediately and adversely ❑YesNo ❑ Homeowner testimony impact or threaten public health or safety electrical, unsafe covers, etc. ? CI Examined for surging in tank Any"yes"answer indicates that the system is an imminent CI “Black soil"above soil dispersal system threat to public health and safety. ❑ System requires"emergency"pumping El Performed dye test Does the system pose a threat to ground water for any conditions deemed non- CI Yes No [11 Other: •rotective as determined b the ins•ector? "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, in sequential order, nor does it indicate which combinations are necessary to make this determination. 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. Completed form must be submitted to the local unit of government within 15 days. Property owner name(s): Property address: ___J ®Q ‘.)d 44, e," Property owner's address(if different): -- — County: ____6/5-1 ,1(.." Phone: I hereby certify that I personally made the observations, interpretations, and conclusions reported on this form and that they are correct. /" • Name: j®/dt✓i e h,+�z--A---- �,� Certification number: Business license name and number: ht C 71k v Name of local un' go rnment: - ®be®es Signature: IP" /6 „P ... f.4 i i. . Date: o vq-wwists4-31 I/1/08 Compliance Inspection Form for Existing SSTS • Parcel number: System status: Compliant ❑Noncompliant (as determined y his form) Operating Permit Compliance and Nitrogen BMP Compliance Compliance Issue #4 of 4 Applicability: • Is the system operated under an Operating Permit? ❑Yes Zo If"yes",then complete item A, below Is the system required to employ a nitrogen BMP? ❑Yes No If"yes",then complete item B, If the answer to both questions is "no'; then this form does not need to be completed. below Compliance questions/criteria: (Required) (Check the appropriate box) A. For systems with operating permits: Has all the required monitoring and maintenance taken place and does the monitoring indicate compliance with the permit thresholds? ❑ Yes ❑No B. For a system that has a required nitrogen reducing BMP and does not have an operating permit: Is the nitrogen BMP in-place and appears to be properly operating? ❑Yes ❑No Any"no"answers indicates noncompliance Date of observation: V r? Reason for observation: V / /L - - Operating permit number: . This form expires upon next inspection or in three years, whichever occurs first: 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 advanced inspector, service provider, or maintainer(maintainer for holding tanks only). Completed form must be submitted to the local unit of government within 15 days. Property owner name(s): Property address: 9d0 s• iti Property owner's address (if different): County: Phone: I hereby certify that I personally made the observations, interpretations and conclusions reported on this form and that they are correct. Name: t/ Lit✓ Certification number: — -7 6 Business license name and number: or Name of local unit of government: • Signature: Date: q-wwists4-31 -w Compliance Inspection Form for Existing SSTS Parcel number: System status: ❑ Compliant ❑Noncompliant (as determined by this form) Tank Integrity and Safety Compliance Compliance Issue #2 of 4 Date of observation: 0 Reason for observation: This form expires on(three ears : Compliance questions/criteria: (Required) Check the a..ro.riate box Verification Method**: (Optional) Does the system consist of a seepage pit*, (Check the appropriate box) Gess'061, d ell, orleachin. tit? ❑ Yes ❑No ❑ Probed tank bottom Do any sewage tank(s)leak below their ❑ Observed low liquid level desi.ned oaeratinI death? ❑ Yes ❑No ❑ Examined construction records If yes, identify which sewage tank leaks. ❑ Examined empty(pumped)tank Any"yes"answer indicates that the system is failing to protect El Probed outside tank for"black soil" ground water. ❑ Pressure/vacuum check * Seepage pits meeting 7080.2550 may be compliant if allowed CI Other: in ordinance by local permitting authority. **No standard protocol exists. This list is not exhaustive,in L r sequential order, nor does it indicate which combinations are necessary to make this determination. Safety Check 1. Are any maintenance hole covers damaged, cr ckor appeared to be structurally 2. Were all maintenance hole covers replace i unsound? ❑ Yes* ❑ No P secured manner(e.g.,all screws replaced)? 3. Was secondary access restraint present(sa t ,, ❑ Yes ❑No* y pank,econd cover, or safety netting)-highly recommended. 4. Was any other safety/health issue present? ��„vvvv ❑Yes ❑No Explain: 0 ❑Yes* ❑ No *System is an imminent t at t. .ubliktealth and safety. Certification 1 Sly ! f U�tis' (El, ` St�`/lC- �.S This form is to be completed and attached to the Summary Form of t e Minnesota Pollution on Control Agency's /� Inspection Form for Existing Subsurface Sewage Treatment Systems.Observations, interpretations, and conclusions must be g y s(MPGA)Compliance 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): _ Property address: J f o® 14.1 Property owner's address(if different): County: f£�.4-0. Phone: 'hereby certify that l personally made the observations, interpretations, and conclusions reported on this form and.that the :o hereby ,�/ y are Jame: o-.!;al., �l o � �.� usiness license name and number: lit, 44- Certification number: �� ame of local unit of government: 0 1C-i it 7e wJ ° ` or ignature: 6 Date: �� wwists4 31 for — 1/08 Compliance Inspection form FxisilnQ SSTS