HomeMy WebLinkAbout08-11-22 SSTS AbandonmentMinnesota Pollution
Control Agency SSTS Abandonment
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: -Z Z- Reason for abandonment: VIOI�" 2t�—A
Property owner name(s):Q I
Property owner's address: 021 YS- $_t
City: 0 111_'7/1i _
Site address (if different):
City:
Compliance Information
1. All solids and liquids removed from all tanks? Yes E] No
Disposal Site: h ,q
State:
State:
AJ Zip:
2. All electrical devices and devices containing mercury removed? ❑ Yes ❑ No
Disposal Site:
3. All underground sewage tanks crushed and filled with soil or rock material? [Yes ❑ No or
Removed and disposed off site? ❑ Yes ❑ No
Disposal Site:
4. Contaminated materials* removed and disposed off site? ❑ Yes ❑ No tilg
Disposal Site:
5. All underground cavities** crushed and filled with soil or rock material? [% Yes ❑ No or:
Removed and disposed off site? ❑ Yes ❑ No
Disposal Site:
6. Future discharge to system permanently denied? [,Yes ❑ No
Method(s) used:
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 651-296-6300 800-657-3864 TTY 651-282-5332 or 800-657-3864 • Available in alternative formats
wq-wwists4-03 • 11121108 Page 1 of 2
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.
T North
Certification
1 hereby certify the system was abandoned in accordance with Minn. R. 7080.2500 and any local requirements.
Name (please print): � UE L SC H U T h Title: ►-o v` e Kt o- v�
Address: 'I >o 2 -to
City: H
Phone: °763 - `f 9 g7o L
Date: d— l t-7- Z Signature:
State: hA A) Zip: 5� 35/f
License_# if app jpable): (..I 9Z
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