HomeMy WebLinkAbout7-24-24 Septic Inspection certMINNESOTA POLLUTION
CONTROL AGENCY Compliance inspection report form
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.oca.state.mn.us/sites/default/files/wg-wwists4-31a pdf.
Property information Local tracking number:
Parcel ID# or SeciTwp/Range: 2711823320018 Reason for Inspection Propery Transfer
Local regulatory authority info: City of Orono
Property address: 1000 Cox Farm Road
Owner/representative: David Narum Owner's phone: 503-516-9720
Brief system description: Approximately -1300-gallon, 1-1000 gallon septic tanks, 1-1000-gallon lift station and 500 square feet of
mound rock bed.
System status
System status on date (mmlddlyyyy): 7/23/2024
® 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
The existing system is sized for a four bedroom house.
There is 1.5 feet of sand under the rock bed.
TBM: Top of the lift station electric box. ELV.-100.0
The system was verified by Chip's Septic Services on 05/12/2014. See soil borings
Certification
I 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
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: 1000 Cox Farm Road
Business Name: Rusty Olson Soil & percolation Testing Date: 7/23/2024
1. Impact on public health — Compliance component #1 of 5
criteria:
System discharges sewage to the ❑ Yes' ® No
ground surface
System discharges sewage to drain ❑ Yes- ® No
tile or surface waters.
I
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
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 it?
Sewage tank(s) leak below their
designed operating depth?
Attached supporting documentation:
❑ Yes' 0 No ❑ Empty tank(s) viewed by inspector
❑ Yes" allo
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 Companypumped the tanks.
Name of maintenance business:
License number of maintenance business:
Date of maintenance:
® Existing tank integrity assessment (Attach)
Date of maintenance 7/1912024
(mmlddiyyyy): (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: 1000 Cox Farm Road
Business Name: Rusty Olson Soil & percolation Testing Date: 7/23/2024
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?
3d. System not abandoned in accordance with Minn. R. 7080.2500?
*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 ❑
❑ Yes- ® No
❑ Yes" ® No
4. Operating perinit 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 Practices) 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: 1000 Cox Farm Road
Business Name: Rusty Olson Soil & percolation Testing
5. Soil separation — Compliance component #5 of 5
Date of installation 411511997 ❑ Unknown
(mmlddlyyyy)
ShorelandlWellhead protection/Food ® Yes ❑ No
beverage lodging?
Compliance criteria (select ones_
5a.For systems built prior to April 1, 1996, and ❑ Yes ❑ NW
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 7 2, 500 gallons per day)
Drainfield meets the designed vertical
separation distance from periodically
saturated soil or bedrock.
Date: 7/23/2024
Attached supporting documentation:
❑ Soil observation logs completed for the report
® Two previous verifications of required vertical separation
❑ Not applicable (No soil treatment area)
® Yes ❑ Noy Indicate depths or elevations
❑ Yes ❑ No*
*Any "no" answer above indicates the system is
failing to protect groundwater.
Describe verification methods and results:
A. Bottom of distribution media
B. Periodica
C. Svstem s
101 R
i saturated soil/bedrock 1 98.8
D. Required compliance separation*
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.
5911 Dague Ave.
Delano, WIN 55S28
Phone 7 63-9 i 2-2420
Fax 76S-972 217
MPCA License# 219
David Narum
1000 Cox Farm Road
Orono, MN
503-516-9720
Date: July 19, 2024
Baffles: / OFF
Tank Capacity: 1-1300 gallon septic tank. 1-1000 gallon septic tank, 1-1000 gallon punp tank
# of Tanks: 3
Type of `Tanks: Concrete
Gallons Pumped: 3000
Manlioles to Gracie: 'E5 / NO
Comments:
On July 19, 2024, Elmer J. Peterson Co. pumped tanks. No cracks or eater leaking in tanks at the time of
pumping.
NOTE: This is only a tank report. `Phis is not a compliance inspection for point of sale nor does it
replace a compliance inspection.
M MINNESOTA POLLUTION Sewage tank integrity assessment form
CONTROL AGENCY
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.
��/Iwww.pca.state. m n.us/waterlinsoections,
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 (wo-wwists4-31bi. This form can be found on
the MPCAwebsite at https./Iwww.t)ca.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 elate 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 David Narum
Property address: 1000 Cox Farm Road Orono, MN
Local Regulatory Authority:
System status
System status on date (mm/ddlyyyy): 7/19/2024
Parcel ID:
® 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." Lj
The SSTS has a sewage tank that leaks below the designed operating depth - "Failure to Protect ❑Yes ®Na
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 eyes" answer above indicares sewage tank non-compliance
Company information
Company name: Elmer J. Peterson Co
Business license number: 219
Designated Certified Individual (DCI) information
Print name: James L Braegelmann
Certification number:
I personally conducted the work described above as a Designated Certified Individuat 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 fora.
Designated Certified Individual's signature: James L Braegelmann _ Date (mm/dd/yyyy): 7/19I2.02.4
(This document has been electronically signed.)
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wti-wwists4-91 • 5110121 Page 1 of 1
SEPTIC SYSTEM INVENTORY
Site Address: 1000 Cox Farm Rd PID 27-118-23-32-0018
Owner Name: David & Carol Narum
Owner Address: 1000 Cox Farm Road Long Lake MN 55356-
BuildingTvoe: residence installer: Hayes Exc.
Date of Permit: 9 /18196
Svstem TVDe: mound BR's Designed for 4
In Musa?: Yes Shoreland?: Yes
SEPTIC TANKS:
Material: precast concrete Capacitv: 1300, 1000,1000 Tank Filter:
DRAINFIELD:
Treatment Area: 80*40 Soil Boring: yes DF Ht above Wt: 3
WELL DATA
Setbacks - Well Tanks: Well DF: Report In File: Depth: 181
INSPECTION RECORDS
Date Notes
5/12/2014 Compliance Inspection Completed & Passed
5/1/2006 OK
6/30/2004 OK, Pump tanks
7/11/2002 no surfacing,pump tanks
7/17/2000 no surfacing, pump tanks
7/27/1998 no surfacing
4/15/1997 installation
4/15/1997 installation
PUMPOUT RECORDS
Date GallonsOtliquid
3/12/2017 4000 j
5/12/2014 2500
i
8/11/2006 2000
8/11/2006 2000'
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