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Home My WebLink AboutCompliance Inspection Form 10129/2010 11: 29 7634988290 RUST'S PERC TESTING PAGE 02 Minnesota Pollution Compliance Inspection Form w Control Agency 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems (SETS) St.Paul,MN 55155-4194 Instructions on page 7 Parcel number: 26-118-23-41-0009 For Local Tracking Purposes: System status: ®Compliant ❑ Noncompliant (based on all compliance requirements) Summary Form Property Information Property owner name(s): _Richard Seitz Property address: 1185 Wyndmere Road Property owners address(if ditrant): County: Hennepin ` Property owner phone: 952-5.45-1005 Permitting authority: City of Orono Date system constructed: 9/25/84 Reason for Inspection: Point of sale System Description 1-approximately 15M gallon septic tank.,1-approximately 1000 gallon lift station and Approximately Brief system description: 1500 square feet of trench Local permit number: 7624 Number of bedrooms: 5 Design How rate: 1.0 Is the system: In Shoreland area? ❑Yes 0 No In Wellhead Protection Area? ❑Yes ® No An U.S. Environmental Protection System serving a Minnesota Department Agency(EPA) Class V Injedion Well?❑Yes ® No of Heath(MDH) licensed facility? E]Yes M 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): 10/18/2013 ❑ Notice of Noncompliance-For Noncompliant systems: The reason for noncompliance is. This noncompliant system is classified as(check one below): [I 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 neoessary 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: Joseph J.Olson N� Certification number 1255 Business license name and number: Rusty Olson's soil and peroulatlon testing 810 or Name of local unit o government: Signature: _.. Date: 10/23/10`�N^` Required Attachments Inspector Complete, This Inspection Report is_L_pages long. Check compliance forms attached: ®Hydraulic Performance IR Tank Integrity ®Soil Separation ❑Operating Permit Form(if applicable) ®System drawing/Ats-bulli drawing (]An assessment of any local requirements that are different from what Is required on this form ®Soil Boring Logs ❑Abandonrrmrrt form(if appropriate) ❑Other information(list). Upgrade Requiremenfmts (derived}term/Minn,Stet.§115.55)An imminent threat to pubfic health and safety(17PHS)most be upgraded,replaced,or cls use d/seonbnued within fen months of receipt or this notice or wn'hm a shortar perrod If required by local Ordinance.q pre system is failing to protect grawna water,rhe sysfem must bs upgraded,replaced,or its use discontinued within the gee required by local ordinance.If an existing system is not failing as defined In law,and has at least two feet of design soil seperatton,then the system need not be upgraded,repaired,replaced,w its use disconUnued,notwithstanding any local orolnance met is more strict Thls provision does not apply to systems in shoraland areas,Wellhead Protection Areas,or those used in connection with food, beverage,and tonging establishments as defined in low. wq-wwi5ts4-31 Compliance Inspection Form for Existing SSTS 414108 10/29/2010 11: 29 7634988290 RUSTV'S PERC TESTING PAGE 03 5 Parcel number: , 26-118-23-41-0009 System status: ® Compliant ❑Noncompliant (as determined by this loan) Hydraulic Performance and Other Compliance Compliance Issue #1 of 4 Date of observation: 10/18/10 Reason for observation: point of sale _ This form expires upon next inspection or In three years,whichever occurs first: 10/18/13 Compliance questionsicriterla: (Required) Verification Method': (Optional) LCheck the ep vale box) (Check the appropriate box) Does the system discharge sewage to the ❑Yes ®No round surface? ® Searched for surface outlet Does the system discharge ❑ Performed hydraulic test y rge sewage to drain ❑Yes ®No the or surface waters? ED Searched for seeping in yard Does the system cause sewage backup ❑Yes ® No ® Checked for backup in home into dwelling or establishment? -_ El Excessive ponding in soil system/D-boxes Do other situations exist that have the ❑Yes 1Z No potential to immediately and adversely ❑ Homeowner testimony impact or threaten public health or safety ❑ Examined for surging In tank electrical, unsafe covers, etc.)? _ Any"yes"answer indicates that the system/s an Imminent [3 "Bleck soli'above sail dispersal system 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- ❑ Other _P_rotedive es determined b the Inspector? "Yes"Indlcetas that the system is falling to protect ground water.If-yes-, deacrlbe the condidan 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): Richard Seitz Property address: 1185 W j!!gmere Road Property owner's address(K dlfterent): County: Hennepin Phone: 952-545-1005 I hereby certify that I personally made the observations, interpretations, and conclusions reported on this forrn and that they are correct. Name: Joseph J.Olson Certification number: 1255 Business license name and number: Rusty Olson's soil and perculatlon testing 810 or . . Name of local unit of government: Signature: — Date: 1023/10 wq-wwlsrs4-31 Compliance inspection Form for Existing SSTS 414108 10/29/2010 11:29 7634988290 RUSTYS PERC TESTING PAGE 04 Parcel number. 26.118-23-41-0009 SYatem stems: ®Compliant ❑Noncomphant (as deftm*wd by th/s form) Tank Integrity and Sa 4 ty Compliance Compliance Issue#E2 of 4 Date of observation: 10/18/10 Reason for observation: transfer This forte expires on(three years): 10/18/13 Compliance questiona/criteria: (Required) VerUlcation Me~*: (Optional) Check the riaUe (Chace the epprrrp►iete box) Does the system consist of an-paga pmt", ❑Yes ®No cess dr jwell,or ❑ Probed tank bottom Do any sewage tanks)leak below their ❑Yes C@ No ❑ Observed low liquid level ® Examined consbuction records If yes,identify which sewage ❑ Examined empty(pumped)tank tank leaks. 11 Probed outside tank for"black soiP Any'�as"answw Urdkatsa OW go sysaun is fs jing to pm bct ground*Ww. ❑ Pressundvacuum check Seepage pits meeting 70802550 may be compliant if allowedOther: Maintenance rewrt in ordinance by local permang auuarity. "Nb standard palood exists. This ftt is not exhauaw,in seque WW order,nor does a indicalle Wh;ch combinsUms ars necessary to make this determination. Safety Check 1. Are any maintenance hole covers damaged,cracked,or appeared to be structurally unsound? ❑Yes' ®No 2. Were all maintenance hole coven replaced in a secured manner(e.g.,all screws rmpiaoed)? Yes ❑No- 3, Was secondary aocese r9stmint Present(safety pan,second Cover,or safety netting)—highly recommended. ❑Yes No 4. Was any other safety/health issue present? ❑Yes* ®No Explain: ' 'ps ft an Imminent tlueat to public heaft and salW. Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPGA)Compliance Inspection Form for Existling Subsutlacs Sewage Trsabnant Systema.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 Ys. Property owner nan*s): Richard Seitz Property address: 1.185%ndmere Road Property owner's address pfdiftenq: County: Hennepin Phone: It52.645-1005 I hereby cert that l personally made the obserye6ons,interpretations, and condusians reported on this form and that they ars correct. Name: J J.Olson Certification number: 1255 Business license name and number. Rusyf Olson's soil and perculadon testing 810 or Name of local unit Signature: Date: 10/23/10 wq-ww1sts4-31 Compliance 1 414109 nspertion form for Existing SSTS 10/2912010 11:29 7634988290 RUSTYS PERC TESTING PAGE 05 Parcel number: 26-11&23-41-0009 Sysbsm status: ®Compliant ❑Noncompliant (as deftwWned by this fwm) 8011 Separation C0mpllanae and Other Complignae Compliance Issue#t3 of 4 Date Of observation: 10/19M 0 Reason for observation: transw Tft/nlbmwi on on M&farm does not expire. Compliance quest ionelcrNerle: (Required) Verification Method": (Optional) Check ills " fe box (Check the apprcpdate box) For systems built prior to April 1,1988,and not located in Shoreland or Wellhead Protection ® Conducted soil observation(s)(attach boring logs) Area or not serving a food,beverage or ❑ Two previous verifications(attach boring logs) lodging establishment: Does the system have at least a Iwo-foot vertical separation distance from periodically saturated sea or bedrock? Yes 0 NO For rWrFperfonmarm syowm built April 1, 1996,or later or for non-parlbrrnanos systems located in Shoreland.or WeW*ad Protection Sol observation does not expire.Previous observations Arm establishment:serving a food, or looming by bw InCIe conditions hwe et parties am suticient,unless site Does the system have a three-foot vertical separation distance from psriodicelly wturated soil or bedrock?' Yea No For reduced separation distance systems "perfoMWV6'systems under old 7080.0179 or ' INey be reduced by up to 15 percent If allowed In local Type IV or V system under new 7090.2350 or ordinance. 70902400): "No atandard prot000/exists. This list is not exhauaw, Does the system meet the designed vertical m sequerfel order,nor does it ffAwle which soil distance frote►m Psaturated com4inadians are necessary to make bYs Yes No debsmnation. Any"no"ansrwr N►dos[as that tlrs sywwn is firtlfng fo prmbvat gorowld wNw. Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compliance Inspactlon Form For ExIoUng Subsurface Sewage Treatment Systems.Observations,Interpretations,and conclusions must be completed by on inspector or designer.Completed form must be submitted to the ball unit of government vAthln 15 days. Property owner name(s): Richard Seitz Property address: 1195 Wyndmere Road Property owner's address(rt dilrsrsr4): Cly: Henn"n Phone: 952.545-1005 1 hereby cer*that 1 personally made the observations,Intetpretaftm,and concluaions tgxxted on Mls farm and that they are onnect Name: Joseph J.Olson Certification number. 1255 Business license name and number: Rusty Ohmn's soil and RL=Iationtesting 910 or Name of local unit of Signature: Date: 10/23/10 wq-wwtsw-31 Compliance Inspection Form for Existing SSTS 414108 16/29/2610 11:29 7634988290 RUSTVS PERC TESTING PAGE 06 Loos of Soil Borinas License 0910 Location or Project: 1185 Wyndamere Road Borings made by: Rusty Olson's Soil and Perc testing 10/18/2010 Classfcation System: AASHO ; USDS-USDS-SCS X Unified_; Other Auger used(check two): Hand_X� or Power , Flight, Bucket or Probe_X_ Bench mark is top of basement concrete slab. Elv:100.00 Assumed Boring Number 1_Surface elevation_102.0 Mottled Soil at_X_feet 0"-10"Dark brown sandy loam 10yr3/2 H2O present at_X 10"-18"Brown sandy loam 10yr4/4 18"-36"Brown sandy loam 10yr5/4 36"-48" Brown loamy sand 10yr5/4 48"-66" Brown loamy sand 10yr6/4 Boring Number 2 Surface elevation_104.5 Mottled Soil at_X feet 0"-B"Dark brown loam 10yr3/2 H2O present at X_ 5%12"Brown loam 10yr4/4 12"-20"Brown Gay loam 10yr5/4 20"-44" Brown loam 10yr5/4 44"-58" Brown loam 10yr6/4 58"-72" Brown loamy sand 10yr7/4 TBM: Top of garage concrete slab. Elv.-100.00 assumed Bottom of rock in trench*6 Elv.-99.4 Mottled soils not present to an Elv.-97.0 10/29/2010 11:29 7634988290 RUSTYS PERC TESTING PAGE 07 I 1 r mom • 118, �+r AS, p A D8 3fi N7' ZW 23 is 3flR tVI 60 i . 8 1