HomeMy WebLinkAbout1998-07-20 MPCA Septic System Certificate of ComplianceMinnesota Pollution Control Agency (MPCA)
Inspection Form for Existing Septic Svstems
DATE OF INSPECTION: /� TIMS, 01, WEATHER COXDiTIONS Ld ISTS PERF MIT NUMBER:
gf_ASO\ FOR I�Sg�r'T10\ IDE\TiFICA�Q`
()eedrocn addincin Property OHner(s) J U f I l� �LtQ4S�� Telephone (61.
1) varience Site Address 50 C1 ISTEole jgeL f City YW X-1 L4/Al
OCor..ptaint Zip Code County HAA4
$Propem Transfer kbuyer cr $el:er) Fire No. owosb:p Nume
() Ot,`.tr Is system openee up? 1� (D Furl Partial ContraCorflnstallrr name:
Area aith tc:t_ ord:nance Y IJ Township Rsnize Sectior. Q_orters
i S 110� HAS •(s! ever been p+ygped' (f� \ 1 Mr System Built: l
If Yes, ho•+ oRe::? 17`1 1 for what :Cason: outir+eiy'Q asertten: backL;;o sluggish pt_ahtrg Oether
Any repair doni on sysiern? Y What Wren ,By w`o
Usage: C eh:r'c%ublishrert Odwe ling Oseasonal O other No.. 3edroorils Nc. of c;cupants
Water using appliances: $rClou :s washer)4(Dishwath::Gar:age dispcss:'hir:;ool ba `. 1Vatt: cenditior,:-g t nit GSe:f•::eanir.g hu+,,::ifi:r in `t rye
Msrest Surface Rater: = It from which ty;: ofiur*ue water
Check appropriate sewer system component end ir.=icate location on site sket:h on bat': of for -.;-
Tank (sl: Tjnkfs) Material: Soil Trestment.9y=:
Sept:: :ink Fiberglass _ rock trench _ ai'ernativ: system (identity ry;,c)
_ Aer;bic lank � Plastic _ grave! less L-ench � exzerimental syveri (identir: rype)
_ P;:Tp ta:.k Metal _ chamber trench c .ter (identify type)
—Holding talk '4CCnerete _ s:epzge bed
Otter Other x mound
O,IDoO, o at•gradc �.,.Ij7 t
Tank(s) Sarre. I eats Soil treatment area size(s): A0 sq. ft. Depth ofsystcn botterr. from grade: zll Setback: > Sa
CAt1IPLIANCE INSPECTION"
IS tilere or t•ae tti!•e ever been any evidence of: R s- 2ns Exglain
Discharge cf sewage to the ground surface? YES NO '
Discharge of sewage to a surface water? '+iS
A seepage pit, drywell, :esspool or leaching pit? ES . 0
Less than three fee: of vertical separation between :he soil treatment system .M I
boom and saturated sot i or bedrock? `• ES `ti0 Il LtD�
Sewage ba:kup into dtk. Citing or other estab:ishmert ;.: esen::v occu- ng? ' 1-ES
Situations with *,he potential to immediate:y and ads ersely :.npzct cr :area:en
public hca%h or saferyl YES ti0
if YES was v..swered for a'.y of the above ques*.=s,'!:e system. :s failini; according 'o Minn. R. c`.. 7080.0060.
(if wet; seti;acks are violated, a pc:entizi itnmirnt threat to pub:f: health or safety may exis:)
STATUS Or TH Z SYSTEM
Based on the compliance inspection conducted above the system status is iN _DIi�',/�G 7 , therefore,
s �- (Cho se: it c�o j'� "ence OR fa Ling OR feilirg/i-ttni-_nt th eat)
this document is a l`F���f G �l� �L1�11J� }
(Choose: CertiS:ate of Compliance OR Notice of Ncrt:ompiivxe )
LEA7IFICA SfON
I hereby certif; as a state of.vinnesota licensed Inspector, Designer! or Qualified Er-..p:ogee that a:y obsen•ations recorded on :his form are accurate
as of tie Ca:e at :he top of this form for the site stated above. 1 hemby certify that all inspection wo.k was completed sc:crding to ZDPECeb!:
requirements. No det:: mir.ar:on of future hydrauIi: perfc.-insince cari be made due :o ;nl now•n conditions during system cons, ruc.:on, fur tr: water
Lsage o%er the If oft" s; tern, abuse olfths ys::m , an�o: inadequatt ma:n:envice al: os ;hich will ad�ersel. affect the tote of he s; s:en.
lnspec:or's name �� N (print) Phone No.�O[�"�"CLicense aadlo: Registratie + *:u^..be- 2
a,
.�ddtess Q Q
S'gnat,rc t-r Date �` l0
r
Site Sketch:
•. .. .. .. . ' ... .
............. �.. ,
r.. .... ��......
... .. . �... . , ....
;...� �"`... .tc....... .. . .. .......
. - ... .... + . ... ........
. . log'
r ... " . �... .. ...... l 14' �O7— l
.. iw% I
?lease lttdicate the location of: Well. Weil setback to system, dwelling or other estabiish .ant, terk(s). soil treatne-t system,
reserved soil treatment area, curtain drain, propery lines, waterways. and buried tines (those INOT insttlled by the �ti!ity;.
Include sizes and leeglh and approximate distances from faxed reference points such as streets and bt:i!dings. Please atach as -
boil., drawings, inspection reports, Certificv(s) of Comptiar.:e And Notice(S) OfNoncomplivice, if alvailable.
Soil Borings (BR #): Locate each boring on the map above, indicate on the right of the co;ur-.n the soil
texture, stricture, color, depth of each different soil type, evidence of mettiing, bedrock and standing water.
Also indicate if the material is fill.
BR ;" BR # BR # BR 4 BR TM BR #
�I
" 1
I M
IECOP.D DEPTH OF 14OT; L1N� G SEASONAL mrx WATER (AS CETE2� D L•STN'G THE MUNSSELL COLOR BOOK)�R BEDROCK
)N ABOvE LINES 'n C
:omments AID Su.KFA4L �� sli L7/t7C b
iVhat needs :o be completed to bring the above system into complivice if foL-d not !n cec;:iance?
»sistr.. anus �\comp! i,doe111.8.96