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Home My WebLink About9-13-24 SSTS abandonment FormMinnesota 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: 9/13/2024 Property owner name(s): Property owner's address City: Orono Site address (if different): City: Bradley Pass Reason for abandonment: Demo of structure 215 north arm lane Compliance Information 1. All solids and liquids removed from all tanks? ® Yes ElNo 2 3 Disposal Site: City of Waconia, inn State: inn State: All electrical devices and devices containing mercury removed? ®Yes ❑ No Disposal Site: All underground sewage tanks crushed and filled with soil or rock material? ❑Yes ❑ No or Removed and disposed off site? ®Yes ❑ No Disposal Site: Bursch Brothers Inc. recycle yard 4. Contaminated materials* removed and disposed off site? ❑Yes ❑ No Disposal Site: NA 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 Methods) used: All piping rem Zip: 55364 *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 11/21/08 Page 4 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 ` T North 3� Oft 60 Certification 1 hereby certify the system was abandoned in accordance with Minn. R. 7080.2500 and any local requirements. Name (please print): Kevin Bursch Title: President Address: PO Box 55 City: Hanover Phone: 612-221-1 Date: 9/20/2024 Signature: State: Mn License # if applicable): L2424 Zip: 55341 vdww.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 11 /21 /08 Page 2 of 1 R ESIDEN'FIAL & COMMERCIAL %%J RAC SEWER •SEPTIC •EXCAVATING Kothrade SWE, Inc. P.O. Box 210 ° Hanover, MN 55341 763-498-8702 • www,kothrade.com Work Order/Invoice 30405 4 C,- Billing: ��' I S' d ; , Time In: Time Out: Job Site: 0✓ Aim P.O. # Phone: Recommended Service Date: Ot . Item Parts Labor Other Qty. Item Parts Labor Other MISCELLANEOUS LINE CLEANING Service Call/Trip Charge Service Call Tank Compliance Inspection Jetting Truck to Hourly Charge Televising Overtime Charge Main Line (First 50 feet) Flat Rate Fee Additional Footage TANK CLEANING Floor Drain Maintenance Hole Exposed ❑'Yes ❑ No Laundry Line Tanks ❑ 1 P12 ❑ 3 ❑ 4 Kitchen Line Tank Size ' �,7,- :?1/� `�;. Bathroom Line Disposal Miscellaneous Line City Permit Toilet/Urinal Remove/Replace Extra Hose Snake Toilet/Urinal Extra Gallons Sanitizing Extra Back -flushing Parts/Materials Extra Labor Labor Commercial Pumping PUMP REPLACEMENT Sand Disposal Service Call Commercial Waste Transport Digging ❑ Hand ❑ Backhoe RAISING MAINTENANCE HOLE Lift/Sump Pump Service Call Electrical Hardware Digging ❑ Hand ❑ Backhoe Float Switch Riser ❑ Concrete ❑ Plastic Alarm Maintenance Hole Cover Parts/Materials Adjustment Ring Pump Disposal Pipe & Caps Labor Tar & Cement BAFFLE Materials Service Call Cement Disposal Confined Space Entry Delivery Charge Materials Labor Labor Estimates by Kothrade Sewer, Water &Excavating, Inc. ("Kothrade") are based on facts made known to Kothrade as of the date of the estimate, and therefore are subject to change. Costs of labor and materials may vary after the work commences based on unforeseen issues, including , but not limited to, acts or omissions of Customer or third parties or job side conditions. In the event Kothrade determines additional work or materials are necessary, and the cost will exceed the original estimate, Kothrade will seek Customer approval prior to commencing with the additional and/or necessary work. If the Customer is unavailable or cannot be reached, and the work must be completed due to circumstances, Kothrade, in its sole discretion, may complete the work, and Customer shall be responsible for all services, labor and materials used. I authorize and agree to pay Kothrade for the services, labor and materials as itemized & described above. I TOTAL PARTS TOTAL TOTAL OTHER CHARGES �- SALES TAX AND TOTALOf`` " ❑ CHECK El CASH ❑ ON ACCOUNT ElMC-VISA-DISC Customer Signature Kothrade SWE� Inc. Technician Date Customer Signature Kothrade SWE� Inc. Technician Date