HomeMy WebLinkAbout1175 Mooney Lake Drive Septic certMINNESOTA POLLUTION Compliance inspection report form
CONTROL AGENCY p
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 (MPGA) website at https://www.Rca.state.mn.us/sites/defaulV ilestwg-wwists4-31a.pdf.
Property information Local tracking number:
Parcel ID# or Sec/Twp/Range: 2511823410017 Reason for Inspection Property Transfer
Local regulatory authority info: City Of Orono, (952) 249-4600
Property address: 1175 Mooney Lake Drive, Orono _
Owner/representative: Tim Adelmann Owner's phone: 651-592-7767
Brief system description: 2 -1300 -gallon septic tanks, 1 -1300 -gallon lift station and 630 Square feet Rock bed
System status
System status on date (mm/dd/yyyy): 4/2/2024
® Compliant— Certificate of compliance* ❑ Noncompliant— Notice of noncompliance
(Valid for 3 years from report date unless evidence of an Systems failing to protect ground water must be upgraded, replaced, or
imminent threat to public health or safety requiring removal and use discontinued within the time required by local ordinance.
abatement under section 145A.04, subdivision 8 is discovered or
a shorter time frame exists in Local Ordinance.) An imminent threat to public health and safety (ITPNS) must be
upgraded, replaced, or its use discontinued within ten months of receipt
*Note: Compliance indicates conformance with Minn. of this notice or within a shorter period if required by local ordinance or
R. 7080.1500 as of system status date above and does not under section 145A.04 subdivision 8.
guarantee future performance.
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
The system is designed for a five bedroom house.
There is 1,0 feet of sand under the rock bed.
Certification
I hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No detennination 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, 1 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 Certification number: C1255
Inspector signature: Joseph J. Olson License number: L810
(This document has been electronically signed) Phone: 763-498-8779
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):
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Property Address: 1175 Mooney Lake Drive, Orono
Business Name: Rum Olson Soil & percolation Testing
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.
System causes sewage backup into i ❑ 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
ff-IMMIMLMMITFZl
Attached supporting documentation:
❑ Other:
® 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' ® 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:
Elmer J Peterson Company 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 03/29/2024
(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: 1175 Mooney Lake Drive, Orono
Business Name: Rusty Olson Soil & percolation Testing Date: 04/02/2024
3. Other compliance conditions — Compliance component #3 of 5
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:
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
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) ❑
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Property Address: 1175 Mooney Lake Drive, Orono
Business Name: Rusty Olson Soil & percolation Testing
S. Soil separation — Compliance component #5 of 5
Date of installation 11/17/2017 ❑ Unknown
(mm/d&yyyy)
Shoreland/Wellhead protection/Food ® Yes [--]No
beverage lodging?
Compliance criteria (select one): _
5a. For systems built prior to April 1, 1996, and ❑ Yes ❑ No*
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 ® Yes ❑ No*
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" ❑ Yes ❑ No*
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 5 2,500 gallons per day)
Drainfield meets the designed vertical
separation distance from periodically
saturated soil or bedrock.
*Any "no" answer above indicates the system is
failing to protect groundwater.
Describe verification methods and results:
Date: 04/02/2024
Attached supporting documentation:
® Soil observation logs completed for the report
❑ Two previous verifications of required vertical separation
❑ Not applicable (No soil treatment area)
® Soils were verified by the City inspector
Indicate depths or
A. Bottom of distribution media
B. Periodically saturated soil/bedrock
C. System separation
D. Required compliance separation*
97.0
3.0
2.55
*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 (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
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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Tank Report
Elmer J. Peterson Co.
5921 Dague Ave,
Delano, NI mus
Phone 763-9'172-24.20
Fax 763-972-7,2111
MPGA Ncense# 219
Tiro Adelmann
1175 Mooney Lake Drive
Orono, MN
651-592-7767
Baffles: (9 / OFF
Tank Capacity: 3-1300 Gallon Tanks
# of Tanks: 3
Type of Tanks. Concrete
Gallons Pumped: .3000
Manholes to Grade: YES / 1`O
Comments:
Date: March 29, 2024
On March 29, 2024, Elmer J. Peterson Co. uncovered 2nd manhole (8 inches deep) and pumped tanks. 1 st
manhole and lift station manholes to grade. No cracks or water leaking in tanks at the time of pumping.
NOTE: This is only a tank report. This is not a compliance inspection for point of sale nor docs it
replace a compliance inspection.
MINNESOTA POLLUTION Sewage tank integrity assessment form
CONTROL AGENCY g g Y
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.i)ca.state.tnn.us/waterlinspection .
instructions: This form may be completed, and signed, by a Designated Certified Individual i 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 (wg-wwists4-31 bi. This form can be found on
the MPCA website at https:/lwww.pca. state. mn.uslwater/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 compi and is allowable under Minn. R. 70a2.C700, subp. 4(6)(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(1
and (D) and; Minn. R. 7083.073C(C).
Owner information
Owner/Representative Tim Adelmann _
Property address: 1175 Mood Lake Drive, Orono, MN
Local Regulatory Authority:
Parcel ID:
System status
System status on date (mm/dd/yyyy): 3/29/2024
® Certificate of sewage tank compliance ❑ Notice of sewage tank non-compliance
Compliance criteria:
The SSTS has a seepage pit, cesspool, drywell, teaching 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 Designated Certified Individual (DCI) information
Company name: Elmer J. Peterson Co Print name: Jaynes L Br_aeg;elmann
Business license number: 219 Certification number:
i personally conductea the work described above as a Designated Certified Individual of a Minnesota-ficansed SSTS inspection,
maintenance, installation, orservice provider Business. [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: James L Braegelmann Date (mmlddlyyyy): 3_/2912024
(This document has been electronically signed.)
www. pca. state. mn.us
wq-wwists4-91 • 5110121
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Page 1 of 1
V/
DATE TIME
CITY OF ORONO CALLED IN
INSPECTION NOTICE SCHEDULED
PERMIT NO. COMPLETED &AM&U
ADDRESS 'k
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OWNER NO.
CONTRACTOR
3.
DESCRIPTION
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❑ FOOTING
❑ DEMO - FINAL
❑ SEPTIC FINAL
❑ POURED WALL
❑ PLUMBING RI
❑ EXCAV/GRADING/FILLING
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❑ FOUNDATION WATERPROOF
❑ PLUMBING FINAL
❑ TREE REMOVAL
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❑ RADON SLAB
❑ MECHANICAL RI
❑ SITE INSPECTION
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❑ FRAMING
❑ MECHANICAL FINAL
❑ RATED WALLS
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❑ INSULATION
❑ WOOD BURNER/FIREPLACE
❑ COMPLAINT
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❑ FINAL
❑ WATER HOOK-UP
❑ FOLLOW-UP
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❑ AS BUILT -SURVEY
❑ SEWER HOOK-UP
❑ FOUNDATION/REMOVAL
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❑ DEMO -SITE ❑ SEPTIC INSTALL
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OWNERICONTRACTOR TO MEET YOU: � YES _ NO
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❑ WORK SATISFACTORY: PROCEED
❑ PROJECT COMPLETE
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❑ CORRECT WORK A PROCEED
Cl ISSUE CERTIFICATE OF OCCUPANCY
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❑ CORRECT WORK, CALL FOR REINSPECTION
TEMPORARY
BEFORE COVERING
PERMANENT
❑ CORRECT UNSAFE CONDITION WITHIN HOURS. fl PHOTO TAKEN
INSPECTOR WILL RETURN
❑ STOP ORDER POSTED. CALL INSPECTOR
❑CITATION ISSUED
❑ INSPECTION REOUIRED. CALL TO ARRANGE ACCESS.
Call for the next inspection 24 hours in advance. (952) 249-4600
Owner/Contractor on site:
Inspector.
White Copylinspectoes File Canary Copy/Site Notice
City of Orono Septic Asbuiit Form
Address 'k�"aao0. 1175 Mooney Lake Drive Building Use; Residence
Installer: Burns Excavating License# L1888 Date; 11/17/.2017
Septic Tanks: 2-1300 Pump Tank; 1-1300 Bedrooms # 5
System Type: ❑X 1 0 11 D Ill M Mound ❑ Trenches ❑ Pressure Bed ❑ Other
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