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HomeMy WebLinkAbout2011 - Compliance Inspec Form Minnesota Pollution Compliance Inspection Form Control Agency 520 Lafayttte Road North Existing Subsurface Sewage Treatment Systems (SSTS) St,Paul,MN 55155-4194 ,•' Instructions on paste Parcel number: ;'( For Local Tracking Purposes System status: Compliant ❑ Noncompliant IN-)(€311 / (based on all co Alia ce requirements) Summary Form Property Information Aii Property owner name(s): �R 1� Property address: /'70 (k1.� t�rViA.- O1Lff`t. _.. __.. Property owner's address (if different): �,�i/ County: PIMA A 1\fkek-- Prop owner phone: 7..0 "Tlfp -0963 CPeermitting authority: Date system constructed: -g1 O Reason for Inspection: 5c System Description ,/ 9_ Brief system description:pf� 2 0TTQ.,.r2E6-51- Sf{} � -1-4.104S, )c0 lI ter" 14F;Tc�-t -.A/ Local permit number: - Number of bedrooms: Design flow rate: 6,a• Is the system: r In Shoreland area? Yes ❑ No In Wellhead Protection Area? ❑ Yes KNo An U.S. Environmental Protection System serving a Minnesota Department ,,/r Agency (EPA) Class V Injection Well?CI Yes So of Heath (MDH)licensed facility? El Yes e) 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); C ; ❑ 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 0 Not in compliance with opaaraling parr( 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 a.: determination of future system performance has been nor can be made due to unknown conditions during System cork(' ,Cr.:r: possible abuse of the system, inadequ to maintenance, or future water usage. ` Q Name: _.. C t D� Certification number: �1 69.._.. • Business license name and number tC,Q-S r\C— g5ca -..-.. or Name of local un.vi gover. ant: OF ---. -- --- . . i Signature: i . .' 4 L —meow- Date: 1.1 ..... _ . Required Attachments Inspector Complete:This Inspection Report is SPages long• Check comp) a forms attached: Hydraulic Performance Tank Integrity A,Soil Separation ❑Operating Permit Form iii applicable) System drawing/As•built dr wing ❑ An assessment o any local requirements that ate different from what is reCL,iee on !r••; lorrn 0 Sol Bo ng Logs 0 Abandonment form(it appropriate) ❑ Other information(list)' Upgrade Requirements(derived from Minn. Slat. § 115.55)an imminent three(lo public newel and safely(iTPHS)must oe upgraoco.re;.aces its use discontinued within ren months of receipt of this notice or within a shorter period if required by local ordinance,If the system is lading to prow:t g'o..r_ dater,the system must be upgraded,replaced,or its use discontinued within tone time required by local ordinance. II an existing system is not ra,,.r:g Al ter:v: -law, and hes al least iwo feel of design soil separation, then the system need not Sc upgraded.repaired,replaced,or its use drscondnueo nor.:,tns:s::_•:.g;-. local ordinance that is mote strict, This provision does not apply 10 systems in srorerand areas. wellhead Protection Areas,or those used,II;ounce( -: ?"..• oevorage,and lodging establishments as defined in law. wq,wwibrs4.31 Compliance Inspecrion Form for Exts:,ng SSTS a I rr1A 59/T0 39Vd ZTTEEL8?56 sT :ZT TTOZ/be/eT Parcel number: _ System status: Compliant ❑ Noncompliant (as determine by is form) Hydraulic Performance and Other Compliance Compliance Issue #1 of 4 Date of observation: `© �� 1 3 1\ - Reason for observation: 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 ❑Yes No yr Searched for surface outlet ground surface? ® Performed hydraulic test Does the system discharge sewage to drain ❑ Yes ii No tile or surface waters? Searched for seeping in yard Does the system cause sewage backup ❑Yes 1A No 0 Checked for backup in home into dwelling or establishment? ❑ Excessive ponding in soil system/D-boxes Do other situations exist that have the . ❑Yes XNo 0 Homeowner testimony potential to immediately and adversely impact or threaten public health or safety ,xamined for surging in rank (electrical, unsafe covers etc. ? 0 "Black soil"above soil dispersal system Any"yes"answer indicates that the system is an Imminent threat to public health and safety. ❑ System requires"emergency' pumping ❑ Performed dye test Does the system pose a threat to ground ❑Yes sNo ❑ Other: water for any conditions deemed non- 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, - 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. Completedorm must be submitted to the local unit of government within 15 days. cp. Property owner name(s): _8164.421-di Lr E yieryL. i ...__ Property address: /220 "' AY/ t_ R - 0),,e) _..... Property owner's (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: _— N. _._ _ Certification number: 1�p 1 Business license name and number: _ - Co .� �hC � 1 _____. ..-,, or Name of local unit of o rnm=- : / / „ Signature: �-://«i// Date: !t I>I — .....—_... ... wq•wwists4-31 Compliance Inspection Form for Existing 5ST5 411108 • 913/ la 39dd ZTTEEL8ZS6 9T :ZT TT9Z/b0/0T Panel number: System status: Compliant ❑ Noncompliant (as determined y is form) Tank Integrity and Safety Compliance Compliance Issue #2 of 4 c, , Date of observation: ID ( 1 VS ^ Reason for observation: cLt`4✓ This form expires on (three years): .--- —.. -- Compliance questionsicriterla: (Required) Verification Method": (Optional) (Check the appropriate box) (Check the appropriate box) Does the system consist of a seepage pit', ❑Yes KNo 'Probed tank bottom cesspool, drywell,or leaching pit? 0 Observed low liquid level Do any sewage tank(s)leak below their ❑Yes No Examined construction records designed operating depth? If yes,identify which sewage Examined empty(pumped)tank V/P•949 tank leaks. — ❑ Probed outside tank for"black soil" Any "yes"answer indicates that the system Is falling to protect ❑ Pressure/vacuum check ground water. ' ❑ 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' KNO 2. were all maintenance hole covers replaced in a secured manner (e.g., all screws replaced)? gYes 0 No' 3. Was secondary access restraint present(safety pan,second cover,or safety netting)-highly recommended. ❑ Yes 4. Was any other safety/health issue present? ElYes' *No 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. r� Property owner name(s): �Y ,r9 l r^ Airy ----...... — Property address: / 1'70 IIIZ._ Property owner' 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. �,I ,�,�\ (� , ... Name: e� _ ��Ccertification number: CA ?`'1 _„- . _. Business license name and number: - j 01 , VC,... or — Name of local unit 'o'er • c t: I //— `/— -- Signature: f• -,,,.4--) �/, -- - Date: f'F/ tf.” - -- wq•wwists4.3 Compliance Inspection Form for Existing SSTS 4/1/08 Sia/CO 39dd ZTIEEL8Z56 9T :ZT tTI3Z/1713/0t Parcel number ___ — System status: (Compliant 0 Noncompliant -- (as determined by this form) Soil Separation Compliance and Other Compliance Compliance Issue #3 of 1 1 ,, Date of observation: 10 11 Reason for observation: ci(h�.tc� -- — This information on this form does 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 +0 Conducted soil observation(s) (attach boring logs) located in Shoreland or Wellhead Protection Area or not serving a food, beverage or 0 Two previous verifications (attach boring logs) lodging establishment: ❑ Other: 11 01 . ''P g!`iot /��N/n- Does the system have at least a two-foot IS - /f.' Y4 v7 e/er1.,14°� vertical separation distance from periodically $ /7 3 saturated soil or bedrock? ■ Yes I No pp ( 2^ For non-performance systems built April 1, ill OA W I 1.a Ot �� _-- 1996,or later or for non-performance systems Soil observation does not expire. Previous observations Areas in er Shorelandfor Bever ad Protection lodging by two independent parties are sufficient, unless site est a l or serving a food.beverage or lodging conditions have been altered. establishment: Does the system have a three-foot vertical separation distance from periodically saturated soil or bedrock?' _ 1_4 Yes I No For reduced separation distance systems (i.e., May be reduced by up to l5 percent if allowed in local "performance"systems under old 7080.0179 or ordinance, Type IV or V system under new 7080. 2350 or 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 combinations are necessary to make this separation distance from periodically saturated determination. soil or bedrock?' 0 Yes pa No,-•_ 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): ___5kr t _`I gikr Property address: . 1270 We ger/ owner's address(if different): -- ' - -- - Phone: ---- - County: _�� �- ---.. •. I hereby certify that I personally made the observations, interpretations, and conclusions reported on this form and that they are correct, - !� `- (� Name: Certification number: t'S�t.(?5"1 _—. ..-- Qdrl�nd S 1�S v\� a.oa. - _ -- or Business license name and number: - Name of local unit vernm- . / / - _-- Signature: i f// ..4 _ Date: AO wq•wwisrs4.31 Compliance Inspection Form for Existing SSTS 4/1/08 50/7e 39dd Z1TEEL8Z96 9T :ZT TT9Z/170/13I 10/04/2011 12:16 9528733112 PAGE 05/05 • (/(77r-r 'P- tiU06J5 -.......... ' , I fret'1' . vrvi' 0(14 -•\,...,...,.): I , -'-ree- L 1 . . 401 i.‘e rt iikeVer • //1 Cl- • 9, Edi ~ r c414; t --S ....' -C) ‘.. ., 1. i„ • . b4.c- +r i F ,, r li 1 • a Via o ( . COC-J 7nnJ7nn•J eel 1 _._._.