HomeMy WebLinkAbout05/09/2022 Septic Compliance InspectionMINNESOTA POLLUTION Compliance inspection report form
CONTROL AGENCY P' h h
520 Lafayette Road North Existing Subsurface Sewage Treatment System (SSTS)
5t. Paul, MN 55155-4194 Doc Type: Compliance and Enforcement
Instructions- Inspector must submit completed form to Local Governmental Unit (LGU) and system owner within 15 days of
final determination of compliance or noncompliance. Instructions for filling out this form are located on the Minnesota Pollution
Control Agency (MPGA) website at https://www.oca.state,mn.us/sites/default/files/wq-wwists4-31a.gdf.
Property information Local tracking number:
Parcel ID# or Sec/Twp/Range: 0911723120002 Reason for Inspection Property Transfer
Local regulatory authority info: City Of Orono, (952) 249-46.0.0 —
Property address: 840 Old Crystal Bay Road S., Orono
Owner/representative: Jeff Dewing Owner's phone: 612-597-0424
Brief system description: 2 -1300 -gallon septic tanks, 1 -1300 -gallon lift station and 630 Square feet Rock bed per City records
System status
System status on date (mmldd/yyyy): 05/09/2022
® Compliant — Certificate of compliance`
(Valid for 3 years from report date unless evidence of an
imminent threat to public health or safety requiring removal and
abatement under section 145A.04, subdivision 8 is discovered or
a shorter time frame exists in Local Ordinance.)
*Note: Compliance indicates conformance with Minn.
R. 7050.1500 as of system status date above and does not
guarantee future performance.
❑ Noncompliant — Notice of noncompliance
Systems failing to protect ground water must be upgraded, replaced, or
use discontinued within the time required by local ordinance.
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 or
under section 145A. 04 subdivision S.
Reason(s) for noncompliance (check all applicable)
❑ Impact on public health (Compliance component #1) — Imminent threat to public health and safety
❑ Tank integrity (Compliance component 92) — Failing to protect groundwater
❑ Other Compliance Conditions (Compliance component #3) — Imminent threat to public health and safety
❑ Other Compliance Conditions (Compliance component #3) — Failing to protect groundwater
❑ System not abandoned according to Minn. R. 7080.2500 (Compliance component #3) — Failing to protect groundwater
❑ Soil separation (Compliance component #5) — Failing to protect groundwater
❑ Operating permit/monitoring plan requirements (Compliance component #4) — Noncompliant - local ordinance applies
Comments or recommendations
The system is designed for a five bedroom house.
There is 1.0 feet of sand under the rock bed,
The soils were verified by the City inspector.9/21/2011 see report.
TBM: Top of iron on the south property line
Certification
1 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.
By typing my name below, I certify the above statements to be true and correct to the best of my knowledge, and that this information can be
used for the purpose of processing this form.
Business name: Rusty Olson Soil & percolation Testing
Inspector signature: Joseph J. Olson
(This document has been electronically signed)
Certification number: 01255
License number: 'L810
Necessary Or locally required supporting documentation (must be attached)
Phone: 763-498-8779
❑ Soil observation logs ❑ System/As-Built ❑ Locally required forms ® Tank Integrity Assessment ❑ Operating Permit
❑ Other information (list):
https://www.pca.state.mn.us 651-296-6300 800-657-3864
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Page 1 of 4
Property Address: 840 Old Crystal Bay Road S., Orono
Business Name: Rusty Olson Soil & percolation Testing
1. Impact on public health — Compliance component #1 of 5
liance criteria:
System discharges sewage to the ❑ Yes- ONO
ground surface
System discharges sewage to drain ❑ Yes` ® No
tile or surface waters.
System causes sewage backup into ❑ Yes` ® No
dwelling or establishment.
Any "yes" answer above indicates the system is an
imminent threat to public health and safety.
Describe verification methods and results:
Visual. Nothing was found
Date: 05/09/2022
Attached supporting documentation:
❑ Other:
ID Not applicable
2. Tank integrity — Compliance component #2 of 5
Compliance criteria:
System consists of a seepage pit,
cesspool, drywell, leaching pit,
or other pit?
Sewage tank(s) leak below their
designed operating depth?
❑ Yes` ® No
❑ Yes' Z No
If yes, which sewage tank(s) leaks:
Any "yes" answer above indicates the system
is failing to protect groundwater.
Describe verification methods and results:
Kothrade Sewer and Warter pumped the tanks.
Attached supporting documentation:
❑ Empty tank(s) viewed by inspector
Name of maintenance business:
License number of maintenance business:
Date of maintenance:
® Existing tank integrity assessment (Attach)
Date of maintenance 05/05/2022
(mm/dd/yyyy): (must be within three years)
(See form instructions to ensure assessment complies with
Minn. R. 7082.0700 subp. 4 B (1))
❑ Tank is Noncompliant (pumping not necessary - explain below)
❑ Other:
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Property Address: 840 Old Crystal Bay Road S., Orono
Business Name:, Rusty Olson Soil & percolation Testing Date: 05/09/2022
I Other compliance conditions — Compliance component #3 of 5
3a. Maintenance hole covers appear to be structurally unsound (damaged, cracked, etc.), or unsecured?
❑ Yes* 0 No ❑ Unknown
3b. Other issues (electrical hazards, etc.) to immediately and adversely impact public health or safety? ❑ Yes* Z No ❑ Unknown
*Yes to 3a or 3b - System is an imminent threat to public health and safety.
3c. System is non -protective of ground water for other conditions as determined by inspector? ❑ Yes* ® No
3d. System not abandoned in accordance with Minn. R. 7080.2500? ❑ Yes* ® No
*Yes to 3c or 3d - System is failing to protect groundwater.
Describe verification methods and results:
Visual. Nothing was found
Attached supporting documentation: ® Not applicable ❑
4. Operating permit and nitrogen BMP* -- Compliance component #4 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 specified in the system design? ❑ Yes ❑ No If "yes", B below is required
BMP = Best Management Practice(s) specified in the system design
!f the answer to both questions is "no", this section does not need to be completed.
Compliance criteria:
a. Have the operating permit requirements been met? ❑ Yes ❑ No
b. Is the required nitrogen BMP in place and properly functioning? ❑ Yes ❑ No
Any "no" answer indicates noncompliance.
Describe verification methods and results:
Attached supporting documentation: ❑ Operating permit (Attach) ❑
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Property Address: 840 Old Crystal Bay Road S., Orono
Business. Name: Rusty Olson Soil & percolation Testing
5. Soil separation — Compliance component #5 of 5
Date of installation 10/24/2011
(mm/ddyyyy)
Shoreland/Wel I head protection/Food
beverage lodging?
Aiance criteria (select
5a. For systems built prior to April 1, 1996, and
not located in Shoreland or Wellhead
Protection Area or not serving a food,
beverage or lodging establishment:
Drainfield has at least a two -foot vertical
separation distance from periodically
saturated soil or bedrock.
5b. Non-performance systems built
April 1, 1995, or later or for non-
performance systems located in Shoreland
or Wellhead Protection Areas or serving a
food, beverage, orlodging establishment:
Drainfield has a three-foot vertical
separation distance from periodically
saturated soil or bedrock.*
5c. "Experimental", "Other, or "Performance"
systems built under pre -2008 Rules;
Type IV or V systems built under 2008
Rules 7080. 2350 or 7080.2400
(Intermediate inspector License required :5
2,500 gallons per day; Advanced Inspector
License required > 2,500 gallons per day)
Drainfield meets the designed vertical
separation distance from periodically
saturated soil or bedrock.
❑ Unknown
Date: 05/09/2022
❑ Yes Z No Attached supporting documentation:
❑ Soil observation logs completed for the report
❑ Two previous verifications of required vertical separation
❑ Yes ❑ No` ❑ Not applicable (No soil treatment area)
® The soils were verified by the
H Yes ❑ No* Indicate depths or
❑ Yes ❑ No*
*Any "no" answer above indicates the system is
failing to protect groundwater.
Describe verification methods and results:
A. Bottom of distribution media
95.6
B. Periodically saturated soil/bedrock 92.6
C. System separation 13.0
lance separation* 12.55
*May be reduced up to 15 percent if allowed by Local
Ordinance.
Upgrade requirements: (Minn. Stat. § 115.55) An imminent threat to public health and safety (ITPIYS) 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.
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M MINNESOTA POLLUTION Sewage tank integrity assessment form
CONTROL AGENCY 1
520 Lafayette Road North Subsurface Sewage
5t. Paul, IVIN 55155-4194 Treatment Systems (SSTS) Program
Doc Type: Compliance and Enforcement
Purpose: 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, only a tank integrity assessment, and may only certify sewage tank compliance status
when entirely completed and signed by a qualified professional. SSTS compliance inspection report forms can be found at:
htlns://www pca.state. .,inn usiwaterlinspections.
Instructions: This form may be completed, and signed, by a Designated Certified Individual (DCI) of a licensed SSTS inspection,
maintenance, installation, or service provider business who personally conducts the necessary procedures to assess the compliance
status of each sewage tank in the system. Only a licensed maintenance business is authorized to pump the tank for assessment. A
copy of this information should be submitted to the system owner and be maintained by the licensed SSTS business for a period of
five (5) years from the assessment date.
When this form is signed by a qualified certified professional, it becomes necessary supporting documentation to an Existing
System Compliance 'Inspection Report: Compliance inspection form - Existino system (wo-wwists4-31b). This form can be found on
the MPCA website at helps /lwww.oca state.mn.u5tw,aterlinspections.
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 an inspection report. This form represents a third party assessment of SSTS
component compliance and is allowable under Minn. R. 7082.0700, subp. 4(B)(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(B),(C),
and (D) and; Minn. R. 7083.0730(C).
Owner information
Owner/Representative James & Heidi Williams
Property address: 840 Old Crystal Bay Rd S
Local Regulatory Authority: City of Orono
System status
Parcel ID: 09-117-23-12-0002
System status on date (mmtddlyyyy):45
'
l�PCertificate of sewage tank compliance ❑ Notice of sewage tank non-compliance
Compliance criteria:
The SSTS has a seepage pit, cesspool, drywell, leaching pit, or other pit - "Failure to Protect '
Groundwater." ❑Yes* �tNo
The SSTS has a sewage tank that leaks below the designed operating depth - "Failure to Protect 0 Yes*No
Groundwater."
The SSTS presents a threat to public safety by reason of structurally unsound (damaged, cracked,
or weak) maintenance hole cover(s) or lids or any other unsafe condition - "Imminent Threat to El Yes* t2 -No
Public Health or Safety."
Any "yes" answer above indicates sewage tank non-compliance
Company information Designated Certified Individual (DCI) information
Company name: Kothrade Sewer, Water & Excavating Inc Print name: Larry Burson
Business license number: L192 Certification number: 09199
1 personally conducted the work described above as a Designated Certified Individual of a Minnesota -licensed SSTS inspection,
maintenance, installation, orservice provider Business. t personally conducted the necessary procedures to assess the compliance
status of each sewage tank in this SSTS.
By typingJsigning my name below, t certify the above statements to be true and correct, to the best of my knowledge, and that
this information can be used for the purpose of processing?his form.
Designated Certified Individual's signature: J t,- Z —0, - Date (mmlddfyyyy):
(This documen has been electronically signed.)
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wq-wwists4-91 • 5/10121 Page 1 pf l
�ATE TIME
CITY OF NO CALLEDIN
INSPECTIONION NOTICE SCHEDULED
PERMIT NO. COMPLETED
ADDRESS oz
OWNER--TELEP NE NO.r"�g'77
CONTRACTOR7G1 S
DESCRIPTION
a '
❑ FOOTING ❑ PLUMBING FINAL ❑ EXCAV/GRADING/FILLING
❑ POURED WALL
❑ MECHANICAL RI
❑ LAKESHORE/WETLANDS
Ll FRAMING
❑ MECHANICAL FINAL
❑ TREE REMOVAL
❑ INSULATION
❑ WOOD BURNERIFIREPLACE
❑ SITE INSPECTION
❑ RADCN SLAB
❑ WATER HOOK-UP
❑ PROGRESS
❑ FINAL
❑ SEWER HOOK-UP
❑ COMPLAINT
DEMO - SITE
❑ SEPTIC MAINZ
❑ FOLLOW-UP
❑ DEMO - FINAL
❑ SEPTIC INSTALL
❑ HARD COVER REMOVAL
❑ PLUMBING Ri
❑ SEPTIC FINAL
❑ FOUNDATION/REMOVAL
OWNERICONTRACTOR TO MEET YOU: YES __"_ NO
COMMENTS:
S
, C p4 fee
o • [ 4-
RKSATISFACTORY: PROCEED
❑ CORRECT WORK & PROCEED
❑ CORRECT WORK, CALL FOR REINSPECTION
BEFORECOVERING
❑ CORRECT UNSAFE CONDITION WITHIN HOURS.
INSPECTORWILL RETURN
❑ STOP ORDER POSTED, CALL INSPECTOR
❑ INSPECTION REQUIRED, CALL TO ARRANGE ACCESS-
❑ PROJECTCOMPLETE
❑ ISSUE CERTIFICATE OF OCCUPANCY
TEMPORARY
PERMANENT
❑ PHOTO TAKEN
❑ CITATION ISSUED
Call for the next inspection 24 hours in advance. (952) 249-4600
OwnedContractor on site:
Inspector. ,4 /3 t -�
White COT-4iLinspei tor's File
Canary CopylSite Notice
SEPTIC SYSTEM INVENTORY
Site Address: 840 Old Crystal Bay Rd S PID 09-117-23-12-0002
Owner Name: James Willimas & Heidi Heizman-Williams
Owner Address: 840 Old Crystal Bay Rd S Wayzata MN 55391-
BuildingTvve: residence Installer: Kothrade
Date of Permit: 10/24/11
Svstem Tvpe: mound BR's Designed for 5
In Musa?: Yes Shoreland?:
SEPTIC TANKS:
Material: concrete precast Capacitv: 1300, 1300, 1300 rank Filter: yes 2nd tqank
DRAINFIELD:
Treatment Area: 630 Soil Boring: yes DF Ht above Wt: 3
WELL DATA
Setbacks - Well Tanks: 100 Well DF: 100 Report In File: Depth: 112
INSPECTION RECORDS
Date j Notes
10/24/2011 new installation mound system
9/10/2003 non-compliant, replace by 12/31/2010
8/28/2001 non-compliant,replace by 12/31/2010
10/29/1999 non -conforming, repair by 12/31/2008
8/13/1997 non -compliant -repair by 12/31/2000
7/23/1993 non-conforming,no surfacing,repair 12/31/95
10/17/199fDF surfacing
7/21/1988 no surfacing
8/19/1986 no surfacing
10/7/1981 no surfacing
PUMPOUT RECORDS
Date GallonsOfLiquid
1/4/2019 3000;
6/2/2017 4000
12/16/2014 3500
9/26/2013 3500
10/24/2011 0
9/30/2008 1000
8/10/1993 1000
8/1/1990 1000
7/30/1979 S00
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