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HomeMy WebLinkAbout07-26-2023 Septic Compliance Inspection��MINNESOTA POLLUTION Sewage tank integrity rit assessment form CONTROL AGENCY b b 520 Lafayette Road North Subsurface Sewage St. Paul, MN 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: https://www.pca.state.mn.us/water/inspections. 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 - Existing system (wq-wwists4-31 b). This form can be found on the MPCA website at https://www.pca.state.mn.us/water/inspections. 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 Hanna Miller Buckley Property address: 1570 Fox St Orono MN 55391 Local Regulatory Authority: City of Orono Parcel ID: 021172332007 System status System status on date (mm/dd/yyyy): 7/26/2023 ® Certificate 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 ❑ Yes* ® No Groundwater." The SSTS has a sewage tank that leaks below the designed operating depth - "Failure to Protect ❑ 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 ❑ Yes* ® No Public Health or Safety." Any "yes" answer above indicates sewage tank non-compliance. Company information Company name: Rotz Septic & Excavating Business license number: L3987 Designated Certified Individual (DCI) information Print name: William G Hetzler Certification number: C9963 I personally conducted the work described above as a Designated Certified Individual of a Minnesota -licensed SSTS inspection, maintenance, installation, or service provider Business. I personally conducted the necessary procedures to assess the compliance status of each sewage tank in this SSTS. By typing/signing 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. Designated Certified Individual's signature: Date (mm/dd/yyyy): 7/26/2023 (This document has been electronically signed.) www.pca.state.mn.us 651-296-6300 800-657-3864 Use your preferred relay service Available in alternative formats wq-wwists4-91 • 5/10/21 Page 1 of 1 M�MINNESOTA POLLUTION Compliance inspection report form CONTROL AGENCY 520 Lafayette Road North Existing Subsurface Sewage Treatment System (SSTS) St. 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 (MPCA) website at https://www.l)ca.state.mn.us/sites/default/files/wq-wwists4-31a.1)df. Property information Local tracking number: Parcel ID# or Sec/Twp/Range: 021172332007 Reason for Inspection Property Transfer Local regulatory authority info: City of Orono Property address: 1570 Fox St Orono MN 55319 Owner/representative: Hanna Miller Buckley Owner's phone: Brief system description: Septic Tank(s), Dose Tank, Hybrid Mound, 16" Soil Cover, 12" Sewer Rock as the Method of Distribution System status System status on date (mm/dd/yyyy): 7/26/2023 ® 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. 7080.1500 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 8. 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 #2) — 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 This SSTS would/will continue to benefit from regulalry scheduled service (Pumping). Certification / 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: Rotz Septic & Excavati Inspector signature: Certification number: C9963 License number: L3987 (This document has been electronically signed) Phone: 763.441.2119 Necessary or locally required supporting documentation (must be attached) ® Soil observation logs ® System/As-Built ® Locally required forms ® Tank Integrity Assessment ❑ Operating Permit ® Other information (list): Inner Wellhead Data https://www.pca.state.mn.us 651-296-6300 • 800-657-3864 • Use your preferred relay service • Available in alternative formats wq-wwists4-31b • 4/28/2021 Page 1 of 5 Property Address: 1570 Fox St Orono MN 55319 Business Name: Rotz Septic & Excavating 1. Impact on public health — Compliance component #1 of 5 Compliance criteria: System discharges sewage to the ❑ Yes* ® No ground surface System discharges sewage to drain ❑ Yes" ® No tile or surface waters. Date: 7/26/2023 Attached supporting documentation: ❑ Other: ❑ Not applicable 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 inspection of the immediate area did not identify any type of discharge to surface. 2. Tank integrity — Compliance component #2 of 5 Compliance criteria: System consists of a seepage pit, [--]Yes* ® No cesspool, drywell, leaching pit, or other pit? Sewage tank(s) leak below their [--]Yes* ® No designed operating depth? If yes, which sewage tank(s) leaks: Any "yes" answer above indicates the system is failing to protect groundwater. Attached supporting documentation: ® Empty tank(s) viewed by inspector Name of maintenance business: Rotz License number of maintenance business: L3987 Date of maintenance: 7/26/2023 ❑ Existing tank integrity assessment (Attach) Date of maintenance (mm/dd/yyyy): (must be within three years) (See form instructions to ensure assessment complies with Minn. R. 7082.0700 subp. 4 8 (1)) ❑ Tank is Noncompliant (pumping not necessary - explain below) ❑ Other: Describe verification methods and results: Effluent Levels observed @ Operatong Depth prior to service (Pumping). Emptied Tank(s) did not identify any structural integrity issue(s). Baffles in place. https://www.pca.state.mn.us 651-296-6300 • 800-657-3864 • Use your preferred relay service • Available in alternative formats wq-wwists4-31b • 4/28/2021 Page 2 of 5 Property Address: 1570 Fox St Orono MN 55319 Business Name: Rotz Septic & Excavating 3. Other compliance conditions — Compliance component #3 of 5 Date: 7/26/2023 3a. Maintenance hole covers appear to be structurally unsound (damaged, cracked, etc.), or unsecured? ❑ Yes* ® No ❑ Unknown 3b. Other issues (electrical hazards, etc.) to immediately and adversely impact public health or safety? ❑ Yes* ® 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: Provided 4" Inspection Pipe(s) in the locatin of the existing Rockbed, did not identify any Ponding (Hydraulic Overloading) in the bed. 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 If 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) ❑ https://www.pca.state.mn.us 651-296-6300 • 800-657-3864 • Use your preferred relay service • Available in alternative formats wq-wwists4-31b • 4/28/2021 Page 3 of 5 Property Address: 1570 Fox St Orono MN 55319 Business Name: Rotz Septic & Excavating S. Soil separation — Compliance component #5 of 5 Date of installation 9/20/2017 ❑ Unknown (mm/dd/yyyy) Shoreland/Wellhead protection/Food beverage lodging? aliance 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, 1996, or later or for non- performance systems located in Shoreland or Wellhead Protection Areas or serving a food, beverage, or lodging 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 <_ 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. Date: 7/26/2023 ❑ Yes ® 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) El ® Yes ❑ No* Indicate depths or elevations A. Bottom of distribution media 98.9' B. Periodically saturated soil/bedrock SB1 95.7' SB2 95.5' C. System separation SB1 3.2' SB2 3.4' D. Required compliance separation* 3.0' *May be reduced up to 15 percent if allowed by Local Ordinance. ❑ Yes ❑ No* *Any "no" answer above indicates the system is failing to protect groundwater. Describe verification methods and results: See attached Soil Observation Log(s). Upgrade requirements: (Minn. Stat. § 115.55) 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. 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 https://www.pca.state.mn.us 651-296-6300 • 800-657-3864 • Use your preferred relay service • Available in alternative formats wq-wwists4-31b • 4/28/2021 Page 4 of 5 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. https://www.pca.state.mn.us 651-296-6300 • 800-657-3864 • Use your preferred relay service • Available in alternative formats wq-wwists4-31b • 4/28/2021 Page 5 of 5 Un'IVE&SITY OF Hlf'H&9UU o Nsar SEWAGE J& TREATMENT �� PROGRAM \moi Soil Observation Log Project ID: 03.15.2023 Client: Hanna Miller Buckley Location / Address: 1570 Fox St Orono MN 55319 Soil parent material(s): (Check all that apply) F Outwash ❑ Lacustrine ❑ Loess R Till ❑ Alluvium ❑ Bedrock ❑ Organic Matter ❑ Disturbed/Fill Landscape Position: Shoulder Slope %: 6.0 Slope shape: Convex, Convex Flooding/Run-On potential: No Vegetation: Lawn Soil survey map units: L41 C2 Surface Elevation -Relative to benchmark: 97.7' Date/Time of Day/Weather Conditions: 7/26/2023 11:00 A.M. Sunny Limiting Layer Elevation: 95.7' Observation #/Location: SB1 Adjacent to Mound (Sideslope) Observation Type: Auger Depth (in) Texture Rock Frag. % Matrix Color(s) I Mottle Color(s) I Redox Kind(s) I Indicator(s) I I-------- Structure -----------I Shape Grade Consistence 0-9 Loamy Fine Sand 5% 10YR 3/2 None None Granular Weak Friable 9-16 Loamy Fine Sand 5% 10YR 6/6 None None Single grain Structureless Loose 16-24 Fine Sandy L Loam 5% 10YR 4/6 None None Blocky Moderate Friable 7.5YR 4/6 None None 24 Clay Loam 5% 7.5YR 4/6 10YR 6/2 Depletions S2 Platy Strong Firm Comments: I hereby Certify that I have Completed this work in arrnrrfanr.P with all gnnlicahlt- nrrlinanr.Ps rules and laws. Rotz Septic $ Excavating L3987 7/26/2023 (Designer/ Inspector) l�-ignature) (License #) (Date) Optional Verification: I hereby certify that this soil observation was verified according to Minn. R. 7082.0500 subp. 3 A. The signature below represents an infield verification of the periodically saturated soil or bedrock at the proposed soil treatment and dispersal site. (LGU/Designer/Inspector) (Signature) (Cert #) (Date) Un'IVE&SITY OF Hlf'H&9UU o Nsar SEWAGE J& TREATMENT �� PROGRAM \moi Soil Observation Log Project ID: 03.15.2023 Client: Hanna Miller Buckley Location / Address: 1570 Fox St Orono MN 55319 Soil parent material(s): (Check all that apply) F Outwash ❑ Lacustrine ❑ Loess R Till ❑ Alluvium ❑ Bedrock ❑ Organic Matter ❑ Disturbed/Fill Landscape Position: Shoulder Slope %: 6.0 Slope shape: Convex, Convex Flooding/Run-On potential: No Vegetation: Lawn Soil survey map units: L41 C2 Surface Elevation -Relative to benchmark: 97.5' Date/Time of Day/Weather Conditions: 7/26/2023 11:30 A.M. Sunny Limiting Layer Elevation: 95.5' Observation #/Location: SB2 Adjacent to Mound (Sideslope) Observation Type: Auger Depth (in) Texture Rock Frag. % Matrix Color(s) I Mottle Color(s) I Redox Kind(s) I Indicator(s) I I-------- Structure -----------I Shape Grade Consistence 0-14 Loamy Fine Sand 5% 10YR 3/2 None None Granular Weak Friable 14-20 Loamy Fine Sand 5% 10YR 6/6 None None Single grain Structureless Loose 20 Fine Sandy Loam 5% 10YR 4/6 10YR 6/2 Depletions S2 Blocky Moderate Friable 20-24 Fine Sandy Loam 5% 7.5YR 4/6 10YR 6/2 Depletions S2 Blocky Moderate Friable 24 Clay Loam 5% 7.5YR 4/6 10YR 6/2 Depletions S2 Platy Strong Firm Comments: I hereby Certify that I have Completed this work in arrnrrfanr.P with all gnnlicahlt- nrrlinanr.Ps rules and laws. Rotz Septic $ Excavating L3987 7/26/2023 (Designer/ Inspector) l�-ignature) (License #) (Date) Optional Verification: I hereby certify that this soil observation was verified according to Minn. R. 7082.0500 subp. 3 A. The signature below represents an infield verification of the periodically saturated soil or bedrock at the proposed soil treatment and dispersal site. (LGU/Designer/Inspector) (Signature) (Cert #) (Date) Textures: C Clay SiC Silty Clay SC Sandy Clay CL Clay Loam SiCL Silty Clay Loam SCL Sandy Clay Loam Si Silt SiL Silt Loam L Loam SL Sandy Loam* LS Loamy Sand* S Sand* Shape: Grade: Consistence: *Sand Modifiers: Co Coarse M Medium F Fine VF Very Fine Topsoil Indicator(s) of Saturation: T1. Wetland Vegetation T2. Depressional Landscape T3. Organic texture or organic modifiers T4. N 2.5/ 0 color T5. Redox features in topsoil T6. Hydraulic indicators ubsoil Indicator(s) of Saturation: 1. Depleted matrix (value >/=4 and chroma </=2) 2. Distinct gray or red redox features (any Matrix Hue) 3. Matrix Hue of 5Y with a chroma </= 3 4. Matrix Hue of 7.5 YR or redder with faint redox concentrations or redox depletions Granular The Peds are approximately spherical or polyhedral and are commonly found in topsoil. These are the small, rounded peds that hang onto roots when soil is turned over. Platy The peds are flat and plate like. They are oriented horizontally and are usually overlapping. Platy structure is commonly found in forested areas just below the leaf litter or shallow topsoil. Blocky The peds are block -like or polyhedral, and are bounded by flat or slightly rounded surface that are castings of the faces of surrounding peds. Blocky structure is commonly found in the lower topsoil and subsoil. Prismatic Flat or slightly rounded vertical faces bound the individual peds. Peds are distinctly longer vertically, and faces are typically casts or molds of adjoining peds. Prismatic structure is commonly found in the lower subsoil. Single Grain The structure found in a sandy soil. The individual particles are not held together. Loose No peds, sandy soil Weak Poorly formed, indistinct peds, barely observable in place Moderate Well formed, distinct peds, moderately durable and evident, but not distinct in undisturbed soil Strong Durable peds that are quite evident in un -displaced soil, adhere weakly to one another, withstand displacement, and become separated when soil is disturbed Massive No observable aggregates, or no orderly arrangement of natural lines of weakness Loose Intact specimen not available Friable Slight force between fingers Firm Moderate force between fingers Extremely Firm Moderate force between hands or slight foot pressure Rigid Foot pressure 100 �o 90 80 70 0 60 50 Silty o Sandy Clay 40 clay Clay loam Silty clay ^° 30 Sandy clay loam loam mo 20 Sandy Loam Silt loam 10 (od�ys loam Sand as Silt X00 90 80 >0 60 So 90 -Po -�0 7(0 Percent sand Landscape Position: 5unnlut Shoulder BacL Side Foot Sloe Toe Slope Slone Shane: Slope shape is described in two directions: up and down slope (perpendicular to the contour), and across slope (along the horizontal contour); e.g. Linear, Convex or LV'. 1` iL i �L�' 1 �LC x YL 0 F�i� VV VC I � � CL o: a�:w ro+ri7ao.4. Y � ^_ewro. Scr.•ae• f'e� 0 Hennepin County Property Map PARCEL ID: 0211723320007 I ALI fx:�. Date: 7/26/2023 f • r - x 1 inch = 200 feet lib OWNER NAME: Medina Surf Trust PARCEL ADDRESS: 1570 Fox St,Orono MN 55391 PARCEL AREA: 3.16 acres, 137,470 sq ft A -T -B: Abstract SALE PRICE: $1,675,000 SALE DATE: 05/2019 SALE CODE: Warranty Deed ASSESSED 2022, PAYABLE 2023 PROPERTY TYPE: Residential HOMESTEAD: Homestead MARKET VALUE: $3,446,000 TAX TOTAL: $39,506.78 ASSESSED 2023, PAYABLE 2024 PROPERTY TYPE: Residential HOMESTEAD: Homestead MARKET VALUE: $3,750,200 Comments: This data (i) is furnished 'AS IS' with no representation as to completeness or accuracy; (ii) is furnished with no warranty of any kind; and (iii) is not suitable for legal, engineering or surveying purposes. Hennepin County shall not be liable for any damage, injury or loss resulting from this data. COPYRIGHT© HENNEPIN COUNTY 2023 6 ra Q) U dr 1 O d IT 1 i pp 9 F41 ;'.— .9.ml lu* e -AlF old. 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