HomeMy WebLinkAbout1905 Heritage Drive - Septic ComplianceMINNESOTA POLLUTION CONTROL AGENCY SSTS Abandonment Reporting ortin form
Subsurface Sewage Treatment Systems (SSTS)
Doc TypeData Collection
Instructions: This form is offered to meet the abandonment requirements of Minn. R. 7080.2500 and Disclosure Requirements of
Minn. Start. § 115.55, subd. 6. Future water supply well placement can also be affected by an abandoned Subsurface Sewage
Treatment System (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. Please do not send this completed form to the MPCA. 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 Local tracking number:
Date of abandonment: 8/8/2026 Reason for abandonment:
Property owner name(s): Kyle Barker
Property owners address: 1905 Heritage Drive
City: Orono
Site address (rf different):
City:
Compliance Information
1. All solids and liquids removed from all tanks? ® Yes ❑ No
Disposal Site:
State: Minnesota Zip: 55391
E
2. All electrical devices and devices containing mercury removed? ® Yes ❑ No
Disposal Site: Veit Environmental - Metro non hazardous tanks drained previously
3. All underground sewage tanks crushed and filled with soil or rock material? ❑ Yes ® No or
Removed and disposed off site? ® Yes ❑ No
Disposal Site: Veit Environmental - Metro non hazardous tanks drained previously
4. Contaminated material' removed and disposed off site? ❑ Yes ® No
Disposal Site:
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
Method(s) used: Disconnected and Capped
Zip:
*Contaminated materials = Distribution media, soil or said within three feet of the system bottom, distribution pipes, gootexhle fabrwAosin
papenstraw, 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, strop. 1). Does not include chamber media, drop boxes, or distribution boxes.
https.//www.pq.sMe.mn.us 6S1-296-6300 800-657-3864 Use your preferred relay service Available in alternative formats
wq-masts4-03 • 9126125 Page 1 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.
'r North
14.Plastic Tank Removed
Multiflow Removed
Concrete Tank used for forced main to city sewer
Certification
I hereby certify the system was abandoned in accordance with Minn. R. 7080.2500 and any local requirements.
Name (please print): Asher Judd Title: Owner / Operator
Address: 588516P Street N
City: Hugo State: Minnesota Zip: 55038
Phone: 651-983-1976 Licerw6# rapplicable): L4272
Date: f25 Signature:
Please do not send this completed form to the MPCA. 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.
https://www.pcasUte.mn.us • 651-2965300 800-657-3864 Use your preferred May senri a Available in alternative formats
wq-wwisW4-03 • 9126125 vo0e 2 of 2
Jim Eicher
D
Septic Service, LLC
1205 LaBeaux Ave NE
St. Michael, MN 55376
DATE '6- �- 2 �'
Maintenance Inspection Form
MPCA Lic. #L4286
Maintainer 0 Jim
CO i ick
0 Sam
• Phone: 763-497-2764
f
� �-• Email: duaneseptic@centurylink.net
INVOICE
Pumping Fee: y 20
�,2
Name: I " I F
1
Long Pull Fee:
I?
Address: p
i O S
i r,
D• of
I
—I-f -.(. ; /
Other Repairs: + (� g
City/State/Zip:
f7tf oh J
Total Cost of S 14: _
-�
n � �
Payment Method: ❑ Check ❑ Cash ❑ Credit
Tank leaks below the
Tank leaks above the
Maintenance hole cover is damaged,
Tank (check i nt
designed operating depth
designed operating depth
cracked, unsecured, or appears to be
structurally unsound
O'Septic/holding Tank #1
❑Yes
ElNo
❑Yes ❑ No
El Yes ElNo
Gallons: LSJ
❑ Septictholding Tank #2
❑yes
❑ No
❑Yes ❑ No
❑Yes ❑ No
Gallons:
PtmentTank
Gallons:ons:- � 70
ElYes
❑ No
❑ Yes ❑ No
❑ Yes ❑ No
E Pump Tank
❑ Yes
❑ No
❑ Yes ❑ No
❑ Yes ❑ No
Gallons: /o -0
How Accessed:❑ Maintenance HDIe
Scum/Sludge Measured
Maintenance Holes Securely Replaced:
R ason For Pumping:
�c
❑ Other (see attached)
❑ Yes ❑ No
C'1 Yes ❑ No
"+ St t
Did you Identify any operational Issues or unsafe conditions while assessing the sewage tanks In this system, i.e.,
cracked tanks, missing baffles, broken covers, etc.? If so, explain In comments below.
Tank #1 ❑ Yes ❑ No
Tank #2 ❑ Yes ❑ No
Pump Tank ❑ Yes ❑ No
System
❑ Structural Integrity
❑ Structural Integrity
❑ Structural Integrity
❑ Mound
❑ Risers leaking
❑ Risers leaking
❑ Risers leaking
❑ Elevated drainfield
❑ Baffles
❑ Baffles
❑ Baffles
❑ Pressure bed
❑ Non -domestic waste
❑ Non -domestic waste
❑ Electrical issues
❑ Trenches
❑ Non -domestic waste
❑ Ponding/Surfacing
❑ Effluent Filter/screen
❑ Other:
Cleaned? ❑ Yes ❑ No
Comments: lj
Disposal: ❑ Land Application: ❑ Wastewater Treatment Plant
Disposal Site:
Lime:
Gallons
Plowed: ❑ Yes ❑ No
Time:
Temperature:
pH: > 12 ❑
Time:
Temperature:
pH: > 12 ❑
z �r .. i �FQ ® x
a_
TRANSACTION RECORD
Veit Disposal Systems - Metr
14000 Veit Place
Rogers, MN 55374
(763) 428-9564
000502-1309
Invoice #:
Invoice Date:
Payment Transaction Date:
Credit Card #:
Credit Card Type:
Transaction Amount:
Authorization Code:
Veit Disposal Systems - Metro
KBlair 10/06/2025 11:36 AM
OUTDOOR INNOVATIONS -CC
0A
10/06/2025
10/6/2025 11:35:56AM
***********2032
American Express Card
$467.00
Authorization code:127600