HomeMy WebLinkAbout40 orono orchard road tank abadonment form 8-12-24Minnesota Pollution Control Agency SSTS Abandonment
520Lafayette Road North Reporting Form
St. Paulaul,,MMN 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
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Property owner name(s):
David Klema
Property owner's address:
40 Orono Orchard Road
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City: Wayzata (Orono)
State:
MN
Zip: 55391
Site address (if different):
City:
Compliance Information
1. All solids and liquids removed from all tanks? ® Yes ❑ No
Disposal Site:
State:
2. All electrical devices and devices containing mercury removed? ❑ Yes ❑ No IVA
Disposal Site:
3. All underground sewage tanks crushed and filled with soil or rock material? N Yes ❑ No or
Removed and disposed off site? ❑ Yes P9 No
Disposal Site:
4. Contaminated materials' removed and disposed off site? ❑ Yes ❑ No IV A
Disposal Site:
5. All underground cavities" crushed and filled with soil or rock material? ❑ Yes ❑ No or: r,O/r
Removed and disposed off site? ❑ Yes ❑ No
Disposal Site:
6. Future discharge to system permanently denied? ❑ Yes ❑ No NA
Method(s) used:
'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
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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.
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Certification
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I hereby certify the system was abandoned in accordance with Minn. R. 7080, 2500 and any local requirements.
James Braegelmann (Elmer J. Peterson
Name (please print): CCU_ Title: Owner
Address: 5921 Dague Ave. SE
City: Delano State: MN Zip: 55328 _
Phone: 763-972-2420 License # if applicable): 219
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Date: r - t � - ,; �} Signature:
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