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HomeMy WebLinkAbout2014 - Septic Compliance Inspection Minnesota Pollution iiro Control enc Compliance Inspection Form y Existing Subsurface Sewage Treatment Systems 520 Lafayette Road North St.Paul,MN 55155-4194 (SSTS) Doc Type:Compliance and Enforcement Instructions: Inspection results based on Minnesota Pollution Control Agency(MPCA) For local tracking purposes: requirements and attached forms—additional local requirements may also apply. RECEIVED Submit completed form to Local Unit of Government(LUG)and system owner within 15 days SEP 10 2014 System Status CITY OF ORONO System status on date(mm/dd/yyyy): ACompliant- Certificate of Compliance IDNoncompliant- Notice of Noncompliance (Valid for 3 years from report date, unless shorter time (See Upgrade Requirements on page 3) frame outlined in Local Ordinance.) Reason(s)for noncompliance(check all applicable) 0 Impact on Public Health (Compliance Component #1)—Imminent threat to public health and safety El Other Compliance Conditions(Compliance Component#3)—Imminent threat to public health and safety ❑Tank Integrity(Compliance Component #2)—Failing to protect groundwater ❑Other Compliance Conditions(Compliance Component#3)—Failing to protect groundwater ❑Soil Separation(Compliance Component #4)—Failing to protect groundwater ❑ Operating permit/monitoring plan requirements(Compliance Component #5)—Noncompliant Property Information Parcel ID#or Sec/Twp/Range: Property address: /88? g/ c4 ', Reason for inspection: Seac Property owner: Owner's phone: or Owner's representative: Representative phone: Local regulatory authority: t�s / , �.1.1 ex 04,0 Re ulatory authority phone: Brief system description: 4/3 o,� Comments or recommendations: Certification 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. Inspector name: d ex) z=.4.1 Certification number: 75"4 Business name: mi /4.4t 414 S /- rir c ��a.✓ Six.);re License number: „Zi Inspector signature: Phone number: 7 /-1 77 - /7,2 cc Necessary or Locally Required Attachments ❑Soil boring logs J System/As-built drawing ❑ Forms per local ordinance El Other information (list): ,% c.i 7 Ny// www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats wq-wwists4-31 • 1/24/12 Page 1 of 3 Property address: /9$7 63 t y/ /4[.. /etkl, Inspector initials/Date: ,e, VV.V 1. Impact on Public Health— Compliance component#1 of 5 Corn I liance criteria: Verification method(s): Searched for surface outlet System discharge sewage to the ❑Yes No 'round surface. arched for seeping in yard/backup in home System discharge sewage to drain tile ❑Yes KNo ❑ Excessive ponding in soil system/D-boxes or surface waters. ❑ Homeowner testimony(See Comments/Explanation) ❑ "Black soil"above soil dispersal system System cause sewage backup into ❑Yes 4FNo ❑ System requires"emergency'pumping dwelling or establishment. ❑ Performed dye test Any"yes"answer above indicates the system is ❑ Unable to verify(See Comments/Explanation) an Imminent Threat to Public Health and Safety. 0 Other methods not listed(See Comments/Explanation) Comments/Explanation: 2. Tank Integrity—Compliance component#2 of 5 8 �i Compliance criteria: Verification method(s): System consists of a seepage pit, ❑Yes ❑ No ❑ Probed tank(s)bottom cesspool,drywell, or leaching pit. ❑ Examined construction records Seepage pits meeting 7080.2550 may be ❑ Examined Tank Integrity Form(Attach) compliant if allowed in local ordinance. _ ❑ Observed liquid level below operating depth Sewage tank(s)leak below their Li Yes L l No ❑ Examined empty(pumped)tanks(s) • designed operating depth. If yes, which sewage tank(s)leaks: ❑ Probed outside tank(s)for"black soil" ❑ Unable to verify(See Comments/Explanation) Any "yes"answer above indicates the ❑ Other methods not listed(See Comments/Explanation) system is Failing to Protect Groundwater. Comments/Explanation: 3. Other Compliance Conditions—Compliance component#3 of 5 a. Maintenance hole covers are damaged,cracked, unsecured,or appear to structurally unsound. ❑Yes* ❑No ❑Unknown b. Other issues(electrical hazards,etc.)to immediately and adversely impact public health or safety. ❑Yes* ❑No ❑Unknown *System is an imminent threat to public health and safety Explain: c. System is non-protective of ground water for other conditions as determined by inspector ❑Yes* ❑No *System is failing to protect groundwater Explain: www.pca.state.mn.us . 651-296-6300 800-657-3864 TTY 651-282-5332 or 800-657-3864 Available in alternative formats Pnon 7 of 3 Property address: 88? 24, � A.0 Q Inspector initials/Date: 4. Soil Separation- Compliance component#4 of 5 Date of installation: Shoreland/Wellhead protection/Food Beverage ❑Unknown Verification method(s): Lodging? ❑Yes 12-No Soil observation does not expire. Previous soil Compliance criteria observations by two independent patties are sufficient, unless site conditions have been altered or local For systems built prior to April 1, 1996, and M requirements differ. not located in Shoreland or Wellhead � Yes ❑No ,.,/ nducted soil observation(s) (Attach boring logs) Protection Area or not serving a food, !� co 0 Two previous verifications(Attach boring logs) beverage or lodging establishment: 0 Not applicable(Holding tank(s),no grainfield) Drainfield has at least a two foot vertical 0 Unable to verify(See Comments/Explanation) separation distance from periodically saturated soil or bedrock. 0 Other(See Comments/Explanation) Non-performance systems built April 1, 1996, or later or for non-performance ❑Yes No Comments/Explanation. systems located in Shoreland or Wellhead `` Protection Areas or serving a food, �Ot v`��/L �'' /0r..... beverage, or lodging establishment: 4 J Drainfield has a three-foot vertical separation distance from periodically saturated soil or bedrock.* "Experimental'; "Other'; or `Performance" 0 Yes 21/No Indicate depths of elevations systems built under pre-2008 Rules; Type IV or V systems built under 2008 Rules(7080. 2350 or 7080.2400 (Advanced Inspector A. Bottom of distribution media �f '' License required) Drainfield meets the designed A+r B. Perind!caI!y saturated so!!;t;adrek /6 " separation distance from periodically C. S: : :ce saturatedsoildrkAny "no"answer above indicates the sysfem is DRseparation' r?� *May be reduced up to 15 percent if allowed by Local Failin• to Protect Groundwater. Ordinance. 5. Operating Permit and Nitrogen BMP*-Compliance component#5 of 5 ►' Not applicable Is the system operated under an Operating Permit? ❑Yes ❑No If"yes",A below is required Is the system required to employ a Nitrogen BMP? ❑Yes ❑No If"yes", B below is required BMP=Best Management Practice(s)specified in the system design If the answer to both questions is "no", this section does not need to be completed. Com•liance criteria a. Operating Permit number: Have the O•eratin• Permit re•uirements been ❑Yes 0 No b. Is the re•uired nitrogen BMP in 'lace and .ro•erl functioning? 0 Yes 0 No Any "no"answer indicates Noncompliance. Upgrade Requirements (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. vww.pca.state.mn.us • 651-296-6300 0 800-657-3864 • rq-wwists4-31 • 1/24/12 TTY 651-282-5332 or 800-657-3864 . Available in alternative formats • Parcel number: • System status: ompliant 0 Noncompliant (as determin thl f fvir LLC ]X92;:310-Pl. Tank Integrity and Safety Compliance St. Michael, MN 576 Compliance Issue-#2 of 4 Date of observation: 9- Q - C� {Reason for observation: f-tA/Kn- (.7)4490A This form expires on(three years):- 1 - _! • Compliance questions/criteria: (Required) Verification Method**:(Optional) • (Check the appropriate box) (Check the appropriate box) Does the system consist of a seepage pit*, 0 Yes No El Probed tank bottom cesspool,drywell,or leaching pit? in - Do any sewage tank(s) leak below their 0 Yes r_51 No Observed low liquid level designed operating depth? 0 Examined construction records If yes, identify which sewage t Examined empty(pumped)tank tank leaks. , 0 Probed outside tank for"black soil" Any"yes"answer indicates that the system Is failing to protect ground water. 0 Pressure/vacuum check • _I nOther: 3 - 1OOo 6u1. CeO/ eaI * Seepage pits meeting 7080.2550 may be compliant if allowed I in ordinance by local permitting1tk5'authority. ta, **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 p, 1. Are any maintenance hole covers damaged,-cracked,or appeared to be structurally unsound? 0 Yes* L7 rvo 2. Were all maintenance hole covers replaced in a secured manner(e.g.;all screws replaced)? I 'Yes 0 No* 3. Was secondary access restraint present(safety pan,second cover,or safety netting)-highly recommended. L7 res 0 No 4. Was any other safety/health issue present? ❑Yes* Ivo 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): y'4 `] I nk _- Property II ) address: ( � 0 120 e.6� f(r CYJ I 0 r 0 tl fI / A. - Property owner's address(if different): County: n 0,e Phone: I hereby certify that I personally made the observations, interpretations, and conclusions reported on this form and that they are correct. • Name: LJ j� u & t2_t � the / Certification number: C-, C� `� �- �2 • Business license name and number: Uri>7�h 5 eft-)c. �P r V i CF, L E�Lr - or Name of local unit-ot ovemment• 7� p Signature: ,j� � ' -V, Date: 1 - q _ wq-wwists4-311 Compliance Inspection Form for Existing SSTS 4111flR .