HomeMy WebLinkAboutSeptic Abandonment Form.401,
Minnesota Pollution SSTS Abandonment
Control Agency t
520 Lafayette Road North Reporting Form
St. Paul, MN 55155-4194
Subsurface Sewage Treatment Systems (SSTS) Program)
Instructions
This form is offered to meet the abandonment requirements of Minn. R. 7080.2500 and Disclosure Requirements of Minn. Stat.
§ 115.55, subd. 6. Future water supply well placement can also be affected by an abandoned SSTS.
The use of this form is not mandatory; however the information on this form must be submitted to the local government unit (LGU)
within 90 days after the abandonment. This form may be completed by a certified SSTS practitioner or by an individual who has
direct knowledge of how the system was abandoned.
Property Information
Date of abandonment: 9 _z y 1 Reason for abandonment: (I
Property owner name(s): ���lfl '��e14
Property owner's address: Q o Wj � 1 N /
City: (� B► i )-erf l State: Zip:
Site address (if different):
City:
Compliance Information
1. All solids and liquids removed from all tanks? nYes ❑ No
Disposal Site: A/f He 3 ! '! &( C-
State:
2, All electrical devices and devices containing mercury removed? ,Yes ❑ No
Disposal Site:
I All underground sewage tanks crushed and filled with soil or rock material? Yes ❑ No or
Removed and disposed off site? ❑ Yes .a No
Disposal Site: 7"'4t1)4- fl a e-,)'
4. Contaminated materials* removed and disposed off site? ❑ Yes ® No
Disposal Site: f
5. All underground cavities** crushed and filled with soil or rock material? R. Yes ❑ No or:
Removed and disposed off site? ❑ Yes 2 No
Disposal Site: F//!elp
6. Future discharge to system permanently denied? ER Yes ❑ No
Method(s) used: A"6 ri P
Zip:
`Contaminated materials = Distribution media, soil or sand within three feet of the system bottom, distribution pipes, geotextile
fabric/rosin paper/straw, tanks, contaminated soil around leaking tanks, any soil that received sewage
from a surface failure (7080.2500 subp.3).
"Underground cavities = Cesspools, leaching pits, drywells, seepage pits, vault privies, pit privies, pump chambers
(7080.2500 subp. 1). Does not include chamber media, drop boxes, or distribution boxes.
www.pca.state.mn.us • 651-2%-6300 • 800-657-3864 TTY 651-282-5332 or 800-657-3864 • Available in alternative formats
wq-wwists4-03 • 11/21/08 Page 1 oft
Map
Include location of building sewer, septic tank(s), soil dispersal system, cesspools, seepage pits, and other pits. Also
include a permanent reference point(s) and dimensions.
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Certification Certification
i hereby certify the system was abandoned in accordance with Minn. R. 7080.2500 and any local requirements.
Name (please print): / Guc/ WA'-t-(L'(Title:-
Address: 15 o g b o1'Lo C f S
City: cu'� Stater Zip: S�S� J
Phone: -7&� - (, Z - U 7 License # if applicable): _� % ! L/
Date: Y Signature: — �G---�
www.pca.state.mn.us • 651-296-6300 800-657-3864 TTY 651-282-5332 or 800-657-3864 • Available in alternative formats
wq-wwists4-03 • 11121108 Page 2 of 2