HomeMy WebLinkAboutseptic info Oct 15 09 p8: 19a Andy a Julie Kleindl (952] -442-9281 p. 2
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Minnesota Poflution Compl�ance Inspect�on Form
Control Agency
20 Lafayette Road North ��sting Subsurface Sewage Treatment Systems (SSTS)
t Paul,MN 55155-4194 Instructions on page 7
Parcel number. 4� � For Local Tracking Purposes:
System sta�us: Compliant ❑ Noncompliarrt .��
(based on�1!compliance r�quirements) ,, '
r ,
Summa�y Form ` � ��
Propert � Information
Property wner name(s):
Property ddress: 763 Ferndale Road North, Orono MN
�roperty wner's address(if d'rfferent):
County: Henne in Property owner phone: 612-781-2321 Perrnitting authority: Carver Counry
Pate sys m constructed: /��7 Reason for inspection: Property Transfer
System escription
�rief syst m description: a � C �k�,�Jkrrp�� r ✓�OG��HC�7PS
�ocal pe it number: Numbe�of bedrooms: � Design flow rate:
1s the sy tem:
In Shor fand area? �Yes ❑ No In Wellhead Protection Area? ❑Yes �] No
j An U.5 Environmental Protection System serving a Minnesota Department
'I Agen (EPA)Class V Injection Well?❑Yes � No of Heath(MDH) licensed facility? ❑Yes �No
CQftlp�Td Ce StdtUS(Based on state requirements-additional local requirements may also apply.)
�ased on the information gathered and reported on attached forms,the oompliance status of this system is(check one):
�Certifl te of Compliance-valid until (3 years from date of report):
Notice of Noncompliance-For Noncompliant systems:
The reason for noncompliance is: _
Thi noncompliant sysbem is classified as(check one below):
❑ I minent threat to public heatth 8�safety ❑ Failing to protect ground water ❑ Not in compliance with operating perrnit
C�(t't1fIC 1011 (Completed form must oe submitted to the local unit of govemment within 15 days.)
ll hereby rtify thaf a!/the necessary rnforma6on has been gafhe�d to defermine ihe compfiance sfatus of this system. No
c�etermin "on of futu►e system performance has been nor can be made due to unknown conditions during system construction,
Rossible buse of fhe system, inadequate maintenance, or future water usage.
�lame: Andrew Kleindl Certfication number. 2926
�usiness icense name and number: Jim's Excavating &Pumping, LLC or
�lame of I cal unit of govemment: Carver Coun
�ignature _ � r Date: r��)�-!J°�
,r
R�quire At�achments Inspector Complete: This Inspection Report is � pages long.
�heck Co plianCe forms attached: f1�Hydraulic Performance ,�Tank Integrity �5oil Separation ❑Operating Permit Form(if
iapplicab ) ❑ System drawing/As-built drawing ❑An assessment of any local requirements that are different trom what is required on this
fortn j�Soil�oring Logs ❑Abandonment form('rf approp�ate} ❑ Other infoRnation(list):
� I
�� Up9r"d B R@qLLi�eR1EI7t5 (derived fiDm Minn. Stat.§195.55)An imminenf th�aat to public health and salety(lTPHSJ must be upgraded,replaced,or
rts use d continued within ten months ofreceipt of this no6ce o�wdhin a shorter penod ifrequired byloca!ordlnance.If the system is failfng to proted ground
! water,th system must be upg2ded,replaced,orits use discontinued w!lhin Ihe time required by loca!ordinance.If an existing system is not farling as defined rn
law,and as at least fwo feet of design soi!separation,thert the System need not be uppraded,repairecl,replaced,or its use disconf/nued,noAvithstanding any
' loca!ord ance that is more sinct. 7his provision dces not appty Jo systems in shoreland areas,Wellhead Protecthon Aieas,or thase useo'in connecUon wrth food,
beverag,and/odging esfablishments as delned in law.
Oct 15 09 8: 19a Rndy a Julie Kleindl [9521 -442-9�81 p. 3
Parcel num er: System status: �Compliant ❑ Noncompliant
(as detem�ined by this form)
Hydraufrc Performance and Other Compliance
Complia�ce Issue #1 of 4
Date of obs rvation: �6 —�j-Q� Reason for observation: �
This form e�ires upon next inspection or in three years,whichever occu�s first:
Complian�e questions/criteria: (Required) Verifcation Method*: (Optionap
__ Check fhe a �o riate box (Check the appropriate box)
Does the system discharge sewage to the ❑Yes �No Q. Searched for surFace ouUet
__g_round surfaoe?
Does the system discharge sewage to drain ❑Yes � No ❑ Pertormed hydraulic test
tile or surfaoe waters? � Searched for seeping in yard
Does the system cause sewage backup ❑Yes � No ❑ Checked for badcup in home
into dwellin�or establishmeni?
- ❑ Excessive ponding in soil system/D-boxes
Do other sitNations exist that have the ❑Yes No
potential to'mmediately and adversely ❑ Homeowner testimony
impact or th eaten public health or safety ❑ Examined for surging in tank
eledrical,_�nsafe covers, etc_)?
Any"yes"answer indicates ihat the sysfiem is an imminent � �B�ack soil"above soil dispersal system
threat to pu lic health and safety. ❑ System requires"emergenc�T pumping
•- ❑ Performed dye test
Does the sy tem pose a threat to ground ❑Yes �'(No � p�er:
water for an condfions deemed non- — -----�•-•---
rotective a determined b the ins ecto�
"Y�s"indi tes bhat the system is failing to protect
grQurtd water.!f"yes';describe fhe condition noted:
I 'No standard protocol exists. This list is not exhausfrve,
in sequential oroler, not does it indicate which
combinations are necessary fo make this determina6on.
Certific tion
This form is o be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compliance
Inspection orm for Existing Subsurface Sevrage Treatrnent Sysfiems.Observations, interpretations,and conGusions must be
completed b an inspector. Completed form must be submitted to the local unit of govemment within 15 days.
Prqperty ow er name(s):
Property ad ress: 763 Femdale Road Norlh Orono MN �
Property ow ers address(if drfferent):
County: enne in Phone: 612-781-2321
I hereby ce " that!personally made the obseivations, inte�prefa6ons, and conclusions reported on fhis foar►and that they are
correct.
Name: A drew Kleindl Certification number: 2926
Business li nse name and number. Jim's Excavating&Pumping, LLC or
Name of I I unit of govemment- Carver un
signature: Date: /�-/,3�d'�J
Oct 15 09 �8: 19a Rndy a Julie Kleindl [9521 -44�-9z81 p. 4
Parcef numper. System status: �`Compliant ❑ Noncompliant
(as deteimined by this form)
Tank In�egrity and Safety Compliance
Complia�ce Issue #2 of 4
Date of obs�rvation_ _^�Q=�-�._.__ Reason for observa#ion: ���Q P
This form e�Cpires on (three years): _
Complian e questionslcriteria: (Required) Ve�ification Method*`: (Optionaq
(Chec�fhe a rn riate box (Check the appropriate box)
Does the system consist of a seepage pit', ❑Yes �No ❑ Probed tank bottom
cesspool,d ell, or leachin it?
Do any sew�ge tank(s)leak below their � ❑Yes � No ❑ Obseroed low liquid level
desi9ned o eratin de th? ❑ Examined construction records
If yes,iden fy wt�ich sewage �' Examined empty(pumped)tank
tank leaks. I ❑ Probed outside tank for"black soil"
Any"yes" wer indicates thaf the system is fallFng to protect
grqund wa r. ❑ Pressure/vacuum check
❑ Other:
' Seepage its meeting 70802550 may be compliant'rf allowed
in ordina ce by local permitting authority.
"No standard protoco!exists. Thrs list is not exhaustive, in
sequential order, nor does it indicafe which combinations
are necessary to make ihis determination.
Safety C eck
1. Are an maintenance hole covers damaged, cracked,or appeared to be structurally unsound? ❑ Yes` �No
2. Were a1 maintenance hole covers replaced in a secured manner(e.g.,all screws replaced)? �Yes ❑ No'`
3. Was se ndary access restraint present(safety pan,second cover, or safety netting)-highly recommended. ❑Yes f�"No
4_ Was an other safety/health issue present? ❑Yes` �`No
Explain•
*Syste is an imminent threat to public hea/th and safety.
Certifica ion
This forrn is o be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's (MPCA)Compliance
Inspection ortn for Existing Subsurface Sewage Treatment Systems.Observations, interpretations,and conclusions must be
completed an inspector, maintainer,or service provider. Completed form must be submitted to the local unit of governrnent within
15 days.
Property o er name(s)=
Property ad ress: 763 Femdale Road North, Orono MN
Property ow ers address(if d'rfierent):
County: enne in Phone: 612-781-2321
1 hereby ce ' that I personally made the observa�ions, interpr�tatrons, and conclusions reported on this form and that they are
correct.
Name: drew Kleindl Certification number: 2926
Business li nse name and number: Jim's Excavating 8 Pumping,LLC or
Name of lo I unit of govemment: C rver Coun
Signature: _ Daie: /�
�
Oct 15 09 �08: z0a Rndy & Julie Kleindl [9521 -442-9281 p. 5
' I
Parcel nurnp er: System status: ,� Compliant ❑iVoncompliant
I (as determined by this iorm)
Soil SeRaration Compliance and Other Compliance
Complia�ce Issue #3 of 4
Date of obs�rvation: �O-'�-�� Reason for observation: ____�rd p��-� T��a%�
This inform�tion on this form does nof expire.
Complianj�e questionslcriteria: (Required) Verificafion Method'*: (Optionaq
(Check the appiaeriate box (Check fhe appropriate 6ox)
For system�built prior to April 1, 1996, and not ,@� Conducted soil observation(s)(attach boring logs)
located in S�horeland or Wellhead Protection
Area or not�Serving a food,beverage or ❑ Two previous verifications(attach boring logs)
lodging es blishment: ❑ Other:
Does the s}�stem have at least a two-foot ;
vertical sep ration distance from periodically
saturated s il or bedrock? ❑Yes ❑ No
For non-per�ormance systems builtApril 1,
1996,or latgr or for non-performance systems �'—
located in S�oreland or Wellhead Protection Soil observation does not expire.Previous observa6ons
Areas or se mg a food,beverage or lodging by two independenE parties are sufficie�t, unless site
establishm�t: conditions have been altered.
Does the sy�stem have a three-foot vertiql
separation �istance from periodically saturated j
soil or bedr ek?` i Yes ❑ No
For reduce separation distance systems(i.e.,
"performan "systems under old 7080.0179 or ' May be r�duced by up to 15 per�ent if allowed in local
Type IV or system under new 7080. 2350 or oidinance.
7080.2400): '•No standard protocol exists. This list is nof exhaus6ve,
Does the sy tem meet the designed vertical in sequential order, nor does it indicate wh;ch
separation istance from periodically saturated combina6ons are necessary to make this
soil or bedr k?' ❑Yes ❑ No determination.
Any"no"a swer lndicates that fhe system is failing to protect
ground wat r.
Certifica ion
This form is o be completed and attached to the Summary Form of the Minnesota Pollution Control Agenc�s(MPCA) Compliance
Inspection ortn for Existing Subsurface Sewage Treatrnent Systems.Observations,interpretations, and conclusions must be
completed an inspector or designer.Completed form must be submitted to the local unit of govemment within 15 days.
Property ow er name(s):
Property ad ress: 763 Ferndale Road North, Orono MN
Property ow ers address(if different):
County: enne in Phone: 612-781-2321
l heieby ce ' thaf 1 personally made the obsenrations, infeipr�ta6ons, and conclusrons reported on this form and thaf they are
correct.
Name: A drew Kleindl Certification number: 2926
Business li nse name and number: Jim's Excavating 8 Pumping, LLC or
Name of lo I unit of govemment: Carver Coun _
Signature: Dafe: ��1-`'j��'
Oc � 15 09 �08: 20a Rndy a Julie Kleindl [9521 -442-9281 p. 6
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Site Sketch:
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Please indicate the location of: We11,well selbacl:to system,dwelling or olher rstablishment,tank(s),soil treatrnent system,
raserved soil treatrnent area,cuctain draiq property lines,viraterways,and burie�fines(those NOT installcd by the utiliry).
lnclude sizes and length and approximaoe distances fi om fxed ceference points such as streets and 6uildings. Please attach as-
built drawings,i�pection repores,Cert�cate(s)of Compliance and Notice(s)of Noncompliancc,if available.
Soi Borings(BR#): Locate each boring on the map above, indicate on the right of the column the soil
tex ,$tructwe, color,depth of each different soil type,evidence of mottling, bedrock and standing water.
Als indicate if the material is fill.
B BR# BR# BR# BR� BR#
5�3�3 �_ �.,
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RECORD I�EPTH OF MOTTLING,SEASONAL HIGH WATER(AS DETERA�QNED US]NG 77-IE MUNSELL COLOR BOOK)OR BEDROCK 011
ABOVE L[�VES
Comments:I r�/ka BmUe u . in rocx d� �i n� �v�otfl�s u.�d a��c�i
�il v o� /�vr� ;h h �+��.e Q� pYQSP,N� w�;�i, /�fll� ,4 �o i,✓�r r i,r A,.� �Gt vn m i ri
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b�,t aau tck Su�-� haw /a-�y �uw�p hud beeti rurrH,� ��d i�i� �r-ff��c�e�
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.�-A���,.=�� - CITY of ORONO
►� ,`a!�`�f��;�` �,
r�, ��° F�` - �E� Municipal Offices
� '����:xl!��:��-� � �
� ,�9 '�:,�.,;-�; .�¢,�/ Street Address: Mailing Address:
�CEggO i� 2750 Kelley Parkway P.O. Box 66
Orono, MN 55356 Crystal Bay, MN 55323-0066
To Current Owner: Address:
��S ��^� `��t �`�� � /'i/.
City Ordinance 199 requires that each existing on-site sewage treatment system in Orono be inspected every two years.
The on-site sewage treatment system at the above address has been inspected and appears to fall into the categories checked below.
STEM CONFORMITY 1-3 : b
1 'CODE SYSTEM" An ISTS which meets all the location,design and construction standazds of the current Orono Municipal Code.
2 "COMPLIANT SYSTEM" An ISTS which does not meet all the location,design and construction standards of the current Orono Municipa(
Code but does meet the three foot separation requirement or two foot requirement for systems installed 1996 or earlier,and which is not failing or
an imminent threat to public health or safery.
3 "NON-COMPLIANT SYSTEM" A prohibited ISTS;an ISTS located within a designated 100-year flood plain,any ISTS which may
or may not meet all the location,design,or constniction standazds of the current Orono Municipal Code and which is failing for any reason;and
any ISTS with less than three feet of unsaturated soil or sand between the distribution device and the fimiting soil characteristics.
TANK CONDITION(5-7): ��
Tank inspection indicates:
5 Pumpout not needed at this time.
6 Septic tanks must be pumped out this�ear (city code requires tanks to be pumped out once every 3 years.
Tank was last pumped �'��k�� ).
Make sure septic tanks are pumped throuQh manhole and not throu�h white inspectionpipes. This allows for the
proper cleaning. Keen water softner and iron fiiter discharge out of septic svstem.
7 Inspection risers missing-tanks could not be inspected. Inspection risers(4"dia. pipe)must be installed in each tank. If
tanks have not been pumped out within the last three years,they should be pumped out now.
<>�INFIELD CONDITION(8-10): ,�
JDrainfield is dry,no surfacing evident.
9 Some evidence of surfacing, not critical yet.
10 Drainfield is saturated and visibly discharging untreated effluent to the surface. Contact the City Inspector
immediately.Repairs must be completed within 90 days.
COMMENTS: �c��,:r�'-.�I� �c;r'iC� ��- �LSM(� StQfZ �^��S Sv"�^�t/
�--a ��`�-i .
�-�-r�3 �� �1��
Date of Inspection Matt Bolterman - Septic System Inspector
Note: In the event that this inspection report is used to satisfy the requirements for a mortgage or other transfer of property,be advised that this report does not guarantee
or certify that an existing system will continue to function properly,but is merely an opinion of the adequacy of the system under current conditions based on thc available
information.
Telephone(952)249-4600 • Fax(952)2A9-4616
www.ci_mm�o_mn.us
� � °� . . �
o f�. o � .
� ����� �- CITY of ��EiONO
���;�.�'� ti ..
� ;y���n z(� .y MnnicipaI Off3ces
n:�.�:f.i�a,o, G
� � �• •�,;•� �i Street Address: Mailing Address: •
.�ESYiOg �2150 Kelley Parkway P.O. Box 66
Orono, MN 55356 Crystal Bay, MN 55323-0U66
Owner: S A S�c���L?�� � �63 �-er�da�C � /U .
� Address:
Ciry Ordinance I99 requires that each existing on-site se�vage treatment stem in Orono be
sy inspected every two yeazs.
The on-site se�vage treatment system at the above address has been inspected and appears to fall into the categories checked below.
SYS?EM CONFORNIITY 1-3 : � �
1 "CODE SYST'EM" An ISTS which meetc a1i tha locaiion,daign and eocutcuction slandards ofthe cuseat Orona hfunicipal Code.
2 °COi�LIANf SYSTEM" An ISTS which doa aot meet all the location,desigi and constcuction standards of the curceat Orono Muaicipal
Code but dars meet the three foot separation requirement,aad which is not fa�ing or aa immine�threat to public heaIth or saf.:ty.
3 "NON-CO�LIANT SYSTEM" Aprolu'bited ISTS;aa ISTS located withia a daignated 100-year flood piaia,aay ISTS which may
or may not mtd all the locatioq drsign,or consOructioa siandards opth�cuseat prona hluaicipai Coda aad which u failing for any reazoq aad
any ISTS with las than three feet of unsahuafed seil er saad betweea the disinbution device and the limiting;oil characteristics,
TANK CONDITTON(5-10): C� . � � � - �
Tank inspection indicates: .. �
� Pumpout aot neaded at this time.
� Tank must ba pumped out this yrsr (ciry coda req�ires ta�to be pumped out every 3 years. Tank was last pumped �"��-�b �
7 Solids actwac4tion in tanks is at a cricieal a aiti�lleveL Tanks should be pumpad out as soon bs possibla.
8 S}stem is d'ischarging to the surface. Tanks mLLst be pumped out within 48 hours to eliminate surface dischuge.
9 Inspection cisers missing-tanks could not be uupected, Inspection cisers(4"dib pipe)must ba instaltzd in each ta.nk at nest pumpout If tanks
hzve not bern pumped out within the last three yrscs,they shauld ba pumped out now.
1� Inspe�Kiun pipe is locatzd dira;dy ovec Luik ba$le(dots not give amirate maasuremeat of solids accumulation). If tanks hava not bern pumped
out withirt the lnst three yeats,they should be pumptd out now.
DRAINFIELD COi�TDITION 11-14 :
11 DrainField'u dry,ao surfaciag evidtnt �
12 Somr e�ldmce ofsurfacin3,not ccitical yet � � . ' ' • •
13 DrsiaFeld is satunted and visibly discharginq untteated e@lurnt to tha surfaca Contad the City Inspector immediately.Repairs must be
eomp(eted Kitfiia 90 days. .
1=� D�sinfield estrnt and conditioa unknown.
COl�NTs: 5 �/S�e� . \o 0�5 �� �l ��P �-°���C S �� ��� ��v�
r�o Sce� ,�u f--�cr �-��-�.�— \qs�-- �3 ye��S
�--�-`�--0\ �� Gi ��� .
�.���
Date of Inspecaon Sepac Sysicm Inspector � ' '
Note: In ttu evtat that this mspection repad'u used to saiisfy the nquir�meais for a mortgage or otha haasfc oFproperty,be advised thai this repoR does not guaraatx
or cectify that an e�sting sysum will coniinue to functioa propaly,but is maely aa apinion of the adcquary of the systrm under cumat eonditieas based en the avulsble
infocmatioa