HomeMy WebLinkAbout03/02/2021 Compliance inspectionM1 MINNESOTA POLLUTION
CONTROL AGENCY
520 Lafayette Road North
St. Paul, MN 55155-4194
Sewage tank
maintenance reporting form
Subsurface Sewage
Treatment Systems (SSTS) Program
Purpose: Management and maintenance of Subsurface Sewage Treatment Systems (SSTS) are important to ensure resource
protection and long-term and cost-effective sewage treatment. Completion of this form complies with the sewage tank maintenance
requirements under Minn. R. 7080.2450 and 7082.0600. This form may be used to certify the compliance status of the sewage tank
components of the SSTS. This form is not a complete SSTS inspection report and may only certify sewage tank compliance
status when entirely completed and signed on page 3 by a qualified professional.
Instructions: A copy of this information must be submitted to the system owner within 30 days of the maintenance date and be maintained
by the licensed SSTS maintainer business for a period of five (5) years from the maintenance date. Maintenance reporting to the local unit of
government may be required by local ordinance. Check with your local SSTS program for maintenance reporting protocol.
Secure maintenance hole covers
All maintenance hole covers must be returned to service in a sound and durable condition and be capable of withstanding
the anticipated load.
Covers must be re-secured in accordance with Minn. R. 7080.2450, subp. 3, Items C or D:
a) Covers installed under local ordinances adopted after February 4, 2008 must be locked, bolted or screwed or must be 95
pounds in weight. They must be made of material suitable for outdoor use, resistant to ultraviolet degradation and leaks, and
not susceptible to being slid or flipped. They must have a label warning of hazardous conditions inside the tank. All screw
openings must be refastened.
b) Covers installed under local ordinances adopted before February 4, 2008 must either be buried with at least 12 inches of
soil cover or be secured according to the local ordinance in effect before February 4, 2008.
c) Covers must meet item 'a' above when raised to the ground surface or less than 12 inches from the ground surface.
Reporting information
Date of maintenance (mrnicid/yyyy): C3/62/ZZO
Property address:
City: Orono
2700 White Oak Circle
Property owner's name: Robert Knuth
Property-owner's address if different:
City:
Phone number: 316-648-9328
Reason for maintenance: Compliance Inspection
Parcel ID: 0411723420021
State: MN Zip code: 55356
State:
Email address:
I. Did you measure the accumulation of scum and sludge? El Yes
Zip code:
Z No (tank(s) pumped without measuring)
Tank (check if present) Scum Sludge Operating depth Percent full
MI Septic/holding tank #1
1:3 Septic/holding tank #2
II Pretreatment tank
• Pump tank
2. Access used to remove septage: 31 Maintenance hole ID Other (Unless a holding tank, go to #4 below)
3. If the maintenance hole was used, were all covers secured in place? 0 Yes Z No If no, please explain below:
Septic tank covers have over 12 inches of soil over them. Manhole cover was a plastic cover that was used to replace the
concrete manhole. Cannot support the weight of the soil over it. Ground water can seep through lids as they are just used as
covering..
4. If the owner refuses to allow a Subsurface Sewage Treatment System (SSTS) to be pumped through the maintenance
hole, have them complete and sign the following statement.
, refuse to allow the removal of the solids and liquids through the maintenance
(Print owner's name)
hole. I understand that removal of solids and liquids through other access points is not considered a compliant method of
solids removal and does not fulfill the solids removal requirements of Minn. R. 7080.2450 and 7082.0600.
Owner's signature: Date (mm/del/yyyy):
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Property address: 2700 White Oak Circle Parcel ID: 0411723420021
City: Orono State: MN Zip code: 55356
5. Is the tank designed as a leaky tank? (Example: seepage pit, cesspool, cltywell, leaching pit)
Tank #1: 0 Yes El No Verification method used: visial
Tank #2: 0 Yes El No Verification method used: visial
6. Is there evidence of the followin ?
Tank (check if present)
Tank leaks below the
designed operating depth
Tank leaks above the
designed operating depth
Maintenance hole cover is
damaged, cracked, unsecured, or
appears to be structurally unsound
• Septic/holding Tank #1 • Yes • No • Yes IN No Yes • No
• Septic/holding Tank #2 MI Yes II No M Yes M No Yes III No
II Pretreatment Tank II Yes II No • Yes MI No • Yes • No
II Pump Tank • Yes • No I Yes II No • Yes No
Describe detail for any "Yes"
7. How many gallons of septage were removed?
Tank #1: Tank #2: Pretreatment Tank: Pump Tank:
8. Where was the septage taken? 0 Wastewater treatment facility 0 Land application 0 Other
Explanation (Facility name/Site #):
9. Did you identify any operational issues or unsafe conditions while assessing the sewage tanks in this system?
El Yes LI No If yes, identify tank and explain:
0 Evidence of non-domestic waste 0 Baffle(s) condition 0 Effluent screen condition
El Maintenance hole and extensions condition El Other conditions (e.g. structural integrity of tank or lid, electrical hazard, etc.)
The septic tanks structural integrity of the side walls are failing. Concrete was flacking off the walls above the
Explanation: water line. Was able to poke hole through the concrete with tile probe.
10. List any troubleshooting and minor repairs completed or declined by owner:
0 Troubleshooting and repairs conducted: 0 Repairs declined by owner:
Additional comments or suggestions for owner's consideration:
Septic tanks will need to be replaced.
Pumping record
I personally conducted the work described above on behalf of a Minnesota-licensed SS TS Maintenance Business, in compliance
with Minnesota Rules Chapters 7080— 7083:
0 As a noncertified individual who has received proper training, daily work review, and periodic observation, or
El As a designated certified individual of the business listed below.
Company information Employee information
Company name: Chip's Septic Services LLC Print name: Pernel Chip Hentges
Business license number: 2064 Certification number (if applicable):
Email: chipseptic@gnnail.co Phone number: 952-200-3176
Employee's signature: Date (mm/dd/yyyy): 3/2/2021
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Property address:
City: Orono
2700 White Oak Circle Parcel ID: 0411723420021
State: MN Zip code: 55356
Optional section: Sewage Tank Compliance Certification
This form does not represent a complete system inspection report and only certifies sewage tank compliance status.
Instructions: This section of the form may be completed and signed by a Designated Certified Individual (DCI) of a licensed SSTS
Maintenance Business who personally conducts the necessary procedures to assess the compliance status of each sewage tank in
the system.
When this section of the form is signed by a qualified certified professional, it becomes necessary supporting documentation to an
Existing System Compliance Inspection Report: Compliance inspection form - Existing system (wg-wwists4-31b). This form can be
found on the MPCA website at https://www.pca.state.mn.ustwater/ssts-and-msts-technical-and-compliance-criteria.
The information and certified statement on this form is required when existing septic tank compliance status is determined by an
individual other than the SSTS Inspector that submits the inspection report. It represents a third party assessment of SSTS
component compliance and is allowable under Minn. R. 7082.0700, subp. 4 Item (B) subitem (1). This form is valid for a period of
three years beyond the signature date on this form unless a new evaluation is requested by the owner or owner's agent or is
required according to local regulations. Additional Administrative Rule references for this activity can be found at Minn.
R. 7082.0700, subp. 4 Items B, C, and D; 7083.0730 Item C.
0 Certificate of sewage tank compliance
Affirm all three statements:
0 The SSTS does not contain a seepage pit, cesspool,
drywell, leaching pit, or other pit.
0 It does not contain a sewage tank that was designed
to be watertight, but subsequently leaks below the
designed operating depth.
0 It does not represent an imminent safety threat by
reason of unsecured, damaged, or weak
maintenance hole cover(s) or other unsafe condition.
Company information
Company name: Chip's Septic Services LLC
Business license number: 2064
El Notice of sewage tank non-compliance
Select all that apply:
The SSTS has a seepage pit, cesspool, drywell,
leaching pit, or other pit —"Failure to Protect
Groundwater."
El It has a sewage tank that was designed to be
watertight, but subsequently leaks below the designed
operating depth —"Failure to Protect Groundwater."
El It presents a threat to public safety by reason of
unsecured, damaged, or weak maintenance hole
cover(s) or other unsafe condition —"Imminent Threat
to Public Health or Safety."
Designated Certified Individual (DCI) information
Print name: Pernel Chip Hentges
Certification number:
I personally conducted the work described above as a Designated Certified Individual of a Minnesota-licensed SSTS Maintenance
Business. I personally conducted the necessary procedures to assess the compliance status of each sewage tank in this SSTS:
Designated Certified
Individual's signature: Date (mnaidd/yyyy): if),' at,/ ecti
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