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HomeMy WebLinkAboutCompliance Inspection Form 08/01/2008 05:33 7634975011 SPTESTINGINC PAGE 02105 1 :;;, Minnesota Pollution 0M p Hance Inspection Form ;►�xk -Control Agency 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems (SSTS) St.Paul,MN 95155-4194 Instructions on page 7 Parcel number: For Local Tracking Purposes: System status: ❑ Compliant S Noncompliant (based on alf compliance requirements) Summary Form Property Informatio Property owner name(sy % r� � *,� sp�A Property address: � � Property owner's address(Ndiffe�renq: County:X11 Property owner phone; Permitting authority: La'f or - _Lb_ t9'P-t�s.l u Date system constructed: .__)_cl,!2 q Reason for nspection: System Description Brief system description: _ a --low !W ___-0 960 5 a f2!C U F Local permit number: Number o r bedrooms: „ Design flow rats: DOC) Is the system: In Shoreland area? Yes ❑No - In Wellhead Protection Area? [--]Yes No An U.S.Environmental Protection System serving a Minnesota Department Agency(EPA) Class V Injection Well?❑Yes M No of Heath(MDH)licensed facility? ❑Yes No Compliance Status(Based on state requirements—addi ional 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 i f report): IIn Notice of Noncompliance-For Noncompliant systems: The reason for noncompliance is: This noncompliant system is classified as(check o ne below): ❑ Imminent threat to public health&safety ® Fallin to protect ground water ❑Not in compliance with operating permit Certification(Completed form must be submitted to the to ml unit of government within 15 days.) I hereby certify that all the necessary information has been g athered to determine the compliance status of this system.No determination or future system performance has been nor ca i be made due to unknown conditions during system construction, possible abuse of the system,inadequate maintenance, orf fum water usage. Name: � ,���, ( � Certification number: Business license name and number: 5 —� '��'i LCL �� �?,�9��? , r � or Name of local unit of govern ent., Signature: ���-- V'Date; rIT30 D`� Required Attachments Inspector complete:This Inspection Report is pages long. Check compliance forms attached; 0 Hydraulic Performance ❑TaNc Integrity N Soll Separatlon ❑Operating Parmit Form(If applicable) IN System drawing/As-built drawing ❑An e3se"r iont of any local requirements that are different from what is required on this form N Soil Boling Logs ❑Abandonment form(if appropriate ❑Other Infornatlon(11m):"00 Upgrade Requirements(derived Dom Minn.stat.§195,55) 4n Imminent threat to public health and solely(i7PHS)must be upgreded,replaced,or !ts vse dimonrinued within ten montlis of recelpt of this notice or within a i thoner period ifrequhed by local ordinance.If the system is felling to pmtsot ground water,the system must be upgraded,replaced,or its use dlsconflnued wh h1h the Ilmd required by local ordnance./f an exlatlng system is not railing as del/ned In law,and has at/most two foot of dss/gn soAseparallon,then the system n not be upgraded,repaked,replecao;or Hs use discontinued,nolwlthstending any local ordinance that/s more shot'rhts ptoviston does not apply to systerr,a in Mormland ages,Wellhead PAVocaon Ar4w.%or Motto used M oonneeBon wUh rood, beverage,and lodging eatabllahments a*defined in law. wq-wwists4.31 Compliance Inspection Form for Existing SSTS 08/01/2008 05:33 7634975011 SPTESTINGINC PAGE 03/05 h Parcel number: System status: ❑Compliant Noncompliant (es determined by this form) Soil Separation Compliance and Other Compliance Compliance Issue #3 of 4 Date of observation: 2-►7-0 eg Reason for observation: .5 6M This information on this form does not expire. Compliance questionsicriteria: (Required) Verification Method": (Optional) (Check the a ry ►late box ' (Check the appropriate box) For systems built prior to April 1, 1996,and not 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; IMo454ltG7 59 1 ,, .arfaoon��VY�s Does the system have at least a two-foot vertical separation distance from periodically 5"ii'°5 - mar„ J& ? • 21L _saturated soil or bedrock? Yes Jo SO,4<0Y1,i o � -AA 011 �l For non-performance systems built April 1, 1996,or later or for non-performance systems located in Shoreland or Wellhead Protection Soil observation does not expire. Previous observations Areas or serving a food,beverage or lodging by two independent parties are sufficient, unless site establishment: conditions have•been altered. i Does the system have a three-foot vertical separation distance from periodically saturated soil ar 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 local Type IV or V system under new 7060.2350 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?' I Yes o determination. Any"no"answer Indleates that the system/Is failing to protect ground wager. Certification This form is to be completed and attached to the Summary Fonn 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 b a submitted to the local unit of government within 15 days. Property owner name(s): Vj�QAIM Property address; Property owner's address(if different): County: ti„1 do Phone: I hereby celfify that I personally made the observations,,inter pa talions, and conclusions reported on this form and that they are correct. Name: 5'�/ � , . ��� �,,� Certification number: io a r) Business license name and number: 151.T � �,-� i C• W _3 q 1)LA-4 90-m or of local unit of Bove ment: Signature: Date; 7 wq-ww1sts4-31 Compliance Inspection Form for Existing SSTS e/i/nR 08/01/2008 05:33 7634975011 SPTESTINGINC PAGE 04/05 4 Parcel number. System status: ❑Compliant Noncompliant (as determined by this Dorm) Hydraulic Performance and Other Compliance Compliance Issue #1 of 4 Date of observation: _��1 -Q Reason for observation: _!W!%. v%Q%510 ^_ This form expires upon next Inspection or In three years,whichi ver occurs first: Compilance questionsicriteria: (Required) Verification Method": (Optional) (Check the appropriate box) (Check the appropriate box) Does the system discharge sewage to the ❑Yes H No ❑ Searched for surface outlet _q!9und surface? Does the system discharge sewage to drain ❑Yes ❑ No ❑ Performed hydraulic test the or surface waters? _ � _ Searched for seeping in yard 14o Does the system cause sewage backup ❑Yes IJ No ❑ Checked for backup In home into dwelling or establishment? ® Excessive ponding in soil system/D-boxes �Jq Do other situations exist that have the ❑Yes ®No ❑ Homeowner testimony potential to immediately and adversely Impact or threaten public health or safety ❑ Examined for surging in tank (electrical unsafe covers etc.)? "Blaclk soil"above soil dispersal system $4-0 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 ®No water for any conditions deemed non- protective on- Other: rotec ve as determined by tie Inspector? y` "Yes"Indicates that the system is failing to protect ground water.If"yes". describe the condition noted. r' No standard protocol exists. This list Is not exhaustive, in sequential order, nor does it indicate which combinations are neoessery to make this determination. Certification This form is to be completed and attached to the Summary Fort of the Minnesota Pollution Control Agency's(MPGA)Compliance Inspection Form for Existing Subsurface Sewage Treatme Systems.Observations,interpretatons,and conclusions must be completed by an inspector.Completed form must be submitted the local unit of government within 15 days. Property owner name(s): W%"I.jN%4 nig } Property address: Property owner's address(if different): County: .-I.,- 1 Phone: 1 hereby cattily that i personalty made the observations, Interpretations,and conclusions reported on this form and that they are correct. Name: �Gl1��f, �j• $L�k1 vyt� s Certification number: Goa 7 Business license name and number. . , 11 9 r.1��2t�3�!����(o or Name of local unit of government: Signature: —~ y Date: wq-ww1sts4-31 Compliance inspection f=orm for Existing SSTS ejirna • i • y • • v� 01U r in ad OL