HomeMy WebLinkAbout3075 Farview Lane - Septic Pumping ReportMINNESOTA POLLUTION
CONTROL AGENCY
520 Lafayette Road North
St. Paul, MN 55155-4194
Sewage tank
maintenance reporting form
Subsurface Sewage
Treatment Systems (SETS) Program
Doc Type: Compliance and Enforcement
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, only a tank Integrity assessment, 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. Page 3 is
optional and not required to be completed on routine maintenance events.
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): 5/18/2026 Reason for maintenance: Routine Pumping
Property address: 3075 Farview Ln Parcel ID: 04-117-23-33-0006
City: Orono State: MN Zip code: 55356
Property owner's name: Gretchen Stofferahn
Property -owner's address (if different):
City:
State:
Phone number: 612-865-7274 Email address:
Zip code:
1. Did you measure the accumulation of scum and sludge? ❑ Yes Njallo (tank(s) pumped without measuring)
Tank check if resent
Scum
i-
Sludge
Operating depth
Percent full
❑ Septic/holdina tank #1
El Septic/holdingSeptietholding tank #2
❑ Pretreatment tank
Pump tank
2. Access used to remove septage: Maintenance hole ElOther (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.
By typing/signing my name below, I certify the above statements to be true and correct, to the best of my knowledge, and
that this information can be used for the purpose of processing this form.
Owner's signature: Date (mm/dd/yyyy):
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Property address: 3076 Farview Ln
City: Orono State: MN
Parcel ID: 04-117-23-33-0006
Zip code: 55356
S. Is the tank designed as a leaky tank? (Example: seepage pit, ces pool, drywell, leaching pit)
Tank #1: ❑ Yes �B No Verification method used.
Tank #2: ❑ Yes ❑ No Verification method used.
6. Is there evidence of the following?
Tank check if resent
Tank leaks below the
desi ned operating depth
Tank leaks above the
designed operating depth
Maintenance hole cover is
damaged, cracked, unsecured, or
appears to be structural1 unsound
Septic/holdingSepticlholdlng Tank #1
0 Yes
Oft
Q Yes
No
❑ Yes o
❑ Septic/holdingSeptic/holding Tank #2
❑ Ye
0 Yes
No
❑ Yes P No
El Pretreatment Tank
❑ Ye
El Yes
No
❑ Yes 0 No
❑ Pump Tank
❑ Yes
No
❑ Yes
No
El Yes o
Describe detail for any "Yes"
7. How many gallons of septage were removed?
Tank #1: 7WO� Tank #2:_ i W d Pretreatment Tank:
8. Where was the septage taken?
Explanation (Facility name/Site #
Pump Tank: I* C)
facility ❑ Land application ❑ Other
9. Did you -identify any operational issues or unsafe conditions while assessing the sewage tanks in this system?
❑ Ye o 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 anv troubleshooting and minor repairs completed or declined by owner:
Additional comments or suggestions for owner's consideration:
Pumping record
! 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.
By typing/signing my name below, I certify the above statements to be true and correct, to the best of my knowledge, and that
this information can be used for the purpose of processing this form.
Company information Employee information
Company name: Kothrade Sewer, Water & Excavating, Inc Print name: L. Bursch
Business license number: MPCA 192 Certification number: of applicable): C9199
Email: info kothrade.com Phone number: 763-498-8702
Employee's signature: Date (mm/dd/yyyy): y
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