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Home My WebLink About165 Luce Line Ridge - Septic Pumping Report - 2025Septic Tank Pumping/Maintenance Owner Information Date:r` _ � ' �,� Phone: Owner: c� �G:C�T� d' �� I1�,Y� _y�N�a�' Email: Property Address: Owner's Address (if different) n,� (Reason for Pumping: Method of Access: Condition of Tanks: Filter Cleaned ank Leakage Observed: Gallons Removed: # 1 /L-W� #2 Method: Safety Concerns: Recommended Repairs: Comments: Tank Information ❑ Complinace Inspection ❑ Holding Tank P(Maintenance Q'Manholes ❑ Inspection Pipe (holding tanks only) / (Owner's signature req'd if refusing to allow pumping through maintenance hole) Yes Baffles good No Above operating depth Below operting depth e�,o #3 #4 Municipal: Land Applied: G-- — 3 Y/ Alarm working: >e No No N/A N/A Yes (repairs recommended) YesIX (failing to protect groundwater) Pump tank ,�"L ' Total , t Q Location: Watertown Wastewater Facility ❑ Location: MA I hereby certify that 1 have completed this work in accordance with MN 7083.0770 and any local requirements. No determination or guarantee offuture s r vmance has been nor can be made. Chip's Septic Service, LLC & SSTS Swartzer's Sewer Services License 16762 .Babcock Avenue Maintaner Signature #2064 Lester Prairie, MN. 55354 (952) 200-3176 chipseptic@gmail.com revised 312025 Septic Tank Pumping/Maintenance 62/jAI) Owner Information Date: �- q - - Phone: 9 j a,- r2/6- _ G$t Owner: �,/,'L�� Email: Property Address: r Owner's Address (if different) 6-60 fax IC) 2V11 723Y 1400 3 UJr . 2J'-A-a , /111q _ Tank Information Reason for Pumping: ❑ Complinace Inspection ❑ Holding Tank ❑ Maintenance Method of Access: Manholes ❑ Inspection Pipe (holding tanks only) (Owner's signature req'd if refusing to allow pumping through maintenance hole) Condition of Tanks: Filter Cleaned Y Baffles good: Alarm working: Y/ No No No N/A N/A N/A Tank Leakage Observed: Above operating depth Yes/ (repairs recommended) Below operting depth Yes/ (failing to protect groundwater) Gallons Removed: # 1 /S,00 #2 /,ge�e> #3 #4 Pump tank �� jj Total & '� Disposal Method: Municipal: Q Location: Watertown Wastewater Facility Land Applied: ❑ Location: Safety Concerns: 4 orl - A)z�rc �'c/�„�, c� rye 500-c�j -- -/2,16 q- Recommended Repairs: 1 r lei 2-C -/e.. Y.,, c^le, 2 Comments: 1 hereby certify that I have completed this work in accordance with MN 7083.0770 and any local requirements. No determination or guarantee of future sy anee has been nor can be made. Chip's Septic Service, LLC & SSTS Swartzer's Sewer Services License 16762 .Babcock Avenue Maintaner Signature #2064 Lester Prairie, MN. 55354 (952) 200-3176 chipseptic&gma.il.com revised 312025 IMINNESOTA POLLUTION CONTROL AGENCY 520 Lafayette Road North St. Paul, MN 55155-4194 Sewage tank maintenance reporting form Subsurface Sewage Treatment Systems (SSTS) Program Purpose: Management and maintenance of Subsurface Sewage Treatment Systems (SSTS) are important to ensure resource protection and long-term and cost-effective sewage treatment. Completion of this form complies with the sewage tank maintenance requirements under Minn. R. 7080.2450 and 7082.0600. 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 and may only certify sewage tank compliance status when entirely completed and signed on page 3 by a qualified professional. Instructions: A copy of this information must be submitted to the system owner within 30 days of the maintenance date and be maintained by the licensed SSTS maintainer business for a period of five (5) years from the maintenance date. Maintenance reporting to the local unit of government may be required by local ordinance. Check with your local SSTS program for maintenance reporting protocol. Secure maintenance hole covers All maintenance hole covers must be returned to service in a sound and durable condition and be capable of withstanding the anticipated load. Covers must be re -secured in accordance with Minn. R. 7080.2450, subp. 3, Items C or D: a) Covers installed under local ordinances adopted after February 4, 2008 must be locked, bolted or screwed or must be 95 pounds in weight. They must be made of material suitable for outdoor use, resistant to ultraviolet degradation and leaks, and not susceptible to being slid or flipped. They must have a label warning of hazardous conditions inside the tank. All screw openings must be refastened. b) Covers installed under local ordinances adopted before February 4, 2008 must either be buried with at least 12 inches of soil cover or be secured according to the local ordinance in effect before February 4, 2008. c) Covers must meet item 'a' above when raised to the ground surface or less than 12 inches from the ground surface. Reporting information Date of maintenance (mm/dd/yyyy): 7/9/2025 Property address: 2650 Fox Street City: Wayzata Reason for maintenance State: M N Property owner's name: Nick Lee Property -owner's address if different: City: _ State: Phone number: 952-215-68887 Email address: Transfer of Title Parcel ID: 0411723410003 Zip code: 55391 Zip code: Did you measure the accumulation of scum and sludge? ❑ Yes ® No (tank(s) pumped without measuring) Tank (check if present) Scum Sludge Operating depth Percent full ® Septic/holding tank #1 normal level ® Septic/holdingSeptic/holding tank #2 _ normal level ❑ Pretreatment tank ® Pump tank normal level 2. Access used to remove septage: ® Maintenance hole ❑ Other (Unless a holding tank, go to #4 below) 3. If the maintenance hole was used, were all covers secured in place? ® Yes ❑ No If no, please explain below.- 4. If the owner refuses to allow a Subsurface Sewage Treatment System (SSTS) to be pumped through the maintenance hole, have them complete and sign the following statement. I, refuse to allow the removal of the solids and liquids through the maintenance (Print owner's name) hole. I understand that removal of solids and liquids through other access points is not considered a compliant method of solids removal and does not fulfill the solids removal requirements of Minn. R. 7080.2450 and 7082.0600. Owner's signature: Date (mm/dd/yyyy): www.pca.state.mn.us • 651-296-6300 • 800-657-3864 wq-wwists4-38 • 10112118 Use your preferred relay service 0 Available in alternative formats Page 1 of 3 Property address: 2650 Fox Street City: Wayzata State: MN Parcel ID: 0411723410003 Zip code: 55391 5. Is the tank designed as a leaky tank? (Example: seepage pit, cesspool, drywell, leaching pit) Tank #1: ❑ Yes ® No Verification method used: visual Tank #2: ❑ Yes ® No Verification method used: 6. Is there evidence of the following? _Tank check if resent --designed Tank leaks below the operating depth Tank leaks above the designed operating depth Maintenance hole cover is damaged, cracked, unsecured, or appears to be structural) unsound ® Se tic/holdin Tank #1 ❑Yes ®No ❑Yes ®No ❑ Yes ® No ❑ Septic/holding Tank #2 ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No ❑ Pretreatment Tank ❑ Yes ❑ No ❑ Yes ❑ No El Yes [:]No ® Pump Tank ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No Describe detail for any "Yes" 7. How many gallons of septage were removed? r %k.- In �t-- Tank #1: 1300 Tank #2: 1300 Pretreatment Tank: Pump Tank: 750 8. Where was the septage taken? ® Wastewater treatment facility ❑ Land application ❑ Other Explanation (Facility name/Site #): Watertown 9. Did you identify any operational issues or unsafe conditions while assessing the sewage tanks in this system? ❑ Yes ® No If yes, identify tank and explain: ❑ Evidence of non -domestic waste ❑ Baffle(s) condition ❑ Effluent screen condition ❑ Maintenance hole and extensions condition ❑ Other conditions (e.g. structural integrity of tank or lid, electrical hazard, etc.) Explanation: 10. List any troubleshooting and minor repairs completed or declined by owner: ❑ Troubleshooting and repairs conducted: I ❑ Repairs declined by owner: Additional comments or suggestions for owner's consideration: Pumping record I personally conducted the work described above on behalf of a Minnesota -licensed SSTS Maintenance Business, in compliance with Minnesota Rules Chapters 7080 — 7083: ❑ As a noncertified individual who has received proper training, daily work review, and periodic observation, or ® As a designated certified individual of the business listed below. Company information Employee information Company name: Chip's Septic Services Business license number: 2064 Email Employee's signature: .com Print name: Pernel Hentges Certification number: (if applicable): 4761 Phone number: 952-200-3176 Date (mm/dd/yyyy): 7/9/2025 www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • Use your preferred relay service 0 Available in alternative formats wq-wwists4-38 • 10112118 Page 2 of 3 Property address: 2650 Fox City: Wayzata State: M N Optional section: Sewage Tank Compliance Certification Parcel ID: 0411723410003 Zip code: 55391 This form does not represent a complete system inspection report and only certifies sewage tank compliance status. Instructions: This section of the form may be completed and signed by a Designated Certified Individual (DCI) of a licensed SSTS Maintenance Business who personally conducts the necessary procedures to assess the compliance status of each sewage tank in the system. When this section of the 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 (wg-wwists4-31 b). This form can be found on the MPCA website at https://www.Pea.state.mn.ustwater/ssts-and-msts-technical-and-compliance criteria. 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 the inspection report. It represents a third party assessment of SSTS component compliance and is allowable under Minn. R. 7082.0700, subp. 4 Item (B) subitem (1). This form is valid for a period of three years beyond the signature date 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 Items B, C, and D; 7083.0730 Item C. ® Certificate of sewage tank compliance Affirm all three statements: ® The SSTS does not contain a seepage pit, cesspool, drywell, leaching pit, or other pit. ® It does not contain a sewage tank that was designed to be watertight, but subsequently leaks below the designed operating depth. ® It does not represent an imminent safety threat by reason of unsecured, damaged, or weak maintenance hole cover(s) or other unsafe condition. Company information Company name: Chip's Septic Services Business license number: 2064 ❑ Notice of sewage tank non-compliance Select all that apply: ❑ The SSTS has a seepage pit, cesspool, drywell, leaching pit, or other pit — "Failure to Protect Groundwater." ❑ It has a sewage tank that was designed to be watertight, but subsequently leaks below the designed operating depth — "Failure to Protect Groundwater." ❑ It presents a threat to public safety by reason of unsecured, damaged, or weak maintenance hole cover(s) or other unsafe condition — "Imminent Threat to Public Health or Safety." Designated Certified Individual (DCI) information Print name: Pernel Hentges Certification number: 4 I personally conducted the worts described above as a Designated Certified Individual of a Minnesota -licensed SSTS Maintenance Business. I personally conducted the necessary procedures to assess the compliance status of each sewage tank in this SSTS: Designated Certified Individual's signature: _ _ Date (mm/dd/yyyy): 7/c)17_1!1k www.pca.state.mn.us • 651-296-6300 • 800-657-3864 Use your preferred relay service 0 Available in alternative formats wq-wwists4-38 • 10112118 Page 3 of 3