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Home My WebLink Aboutseptic info 08/19/2011 13:55 9528733112 PAGE 01/05 � Minnesota Pollution Campliance Inspection Form Control Agen�y 520LalayetteRoadNorth Existing Subsurf�e Sewage Treatment Systems (SSTS) x S�.PauI,MN55155•4194 Instruc[ions on page � �� Parcel number. " � � For Local TraCking Purposes 5ystem siatus: Compliant ❑ Noncompliant �� .�, (based on aH co lianc@ requirements) � � , Summary Form � � Property Information � Property owner name(s); Property address; �Gll` � Properry owner's address pf different); County: P perty ner phone � Per itting authority: ,- .._,,.._.__....—._ ..._._ Dale system�onstructed: � Reason for inspection: � _ _ __ System Description 8rief system description:l�� _�G��/I ... Locai pertnit number __ Numb r of bedrooms: _� Design flow rate; _.�� . Is the system� i In Shoreland area? ❑Yes �No In Wellhead Proiectlon Area? ❑ Yes rvo An U,S, Environmental Protection System serving a Minnesota Oepartment Agency (EPA) Class V Injection Well?[] Yes �No of Heath (MOH) Ilcensed facilify? ❑ Yc�s �vo /\ COr�lplld�Ce StdtuS(Basedon state requirements–additional local requirements may also apply,) Based on Che infnrmaGon gathered and raported on attached forms,the compliance status oi this system is(cher.k en�� rtificale of ComplianCe–valid until (3 years lrom dete o(report); ________ ❑ Notice of Noncompliance- For Noncompliant systems: The reason For noncompllance is: _ ___ _ _ This noncomplfant system Is classffled as(check one belowj; Q Imminenl t�reat to public health 8 saFety ❑ Failing lo prolecl ground wa�e� ❑ Not in compliance with operat�nq per!�;� CertiflCatlOfl (Completed form must be submitted to the Iocal unit o(government within 15 days,) 1 hereby certify that all the I1eCessary intprmafion has be�n gethered io determine the compliance stafus of this systen� r•�_ deierminafion of futUle system performance has been nor can be made due fo unknown CondifrorlS Ou�ing sysfe�n co��srrc��;,��` poss;ble abuse otlhe system, inadequafe meinfenance, or/uture werer usage. Name: _.��(��]!�lY'[�,��(1.C� CertlFicatlon numbor. ��p�_"1,._..._., Business license name and number: �j.�tQ,S�L, �5��, __.. __._. or Name ot iocal unit of nme , Signature; .'_-- Da�e; _q �_1/... . . .. Required Atta hments Inspector Complete: This Inspection Report is �pages long. Cheek eompl ee fo�ma attached; �ydraulic Performance (�ank Integrlry �il Separalion ❑Operating Perm�l Form i�� applicable) 5yst�m drawinglAs•huilt rarwng ❑An assessmenl oi�hy local requi emenls thal are oiffe�enl �rom wnai is reqwreo On �^�� form ❑ Soi ng Logs ❑ ACanOonment fortn (if approprlate) ❑Otner inlortnation (If�tj: UPgfede ReqUif9R19ntS (d9llvdd(lam MI/1/1.$fBI, § 915,55J An immine�f�A/eal IvpubliCAeallfl and saJety(1TPHS)mustDe upgraoea.��p��cCc ; �ts vse oiscan►inueo wl�hln ron montha d rocelpl ol Ihla nolfce or wlrh/n A sAoRer pe�iod if iepvircd by IoCa!oro'inance.!(!hs system is la�nng ro proie�r;�o,:^� Na�o�.fne systom mvsl De up�re0ed,Ieplaced,or ifs use diaconfinued wilhln IAe lime requ�rea oy�ocal oralnA��e,f!an oY�St�n9 syslem�s�or�a��.;:g a>:ar: _: •• �sw,an0 ner af�ees!luro leel o/Oesipn aoil seDeraf�on,fAen Ihe sysfem need no�bc�pgradod,r�paJrcd,roploced,Of i19 u3Q OrSCOrll�nued.non.,rrs��r,-.:�; �-. roeal o�dmanre Inal is�r+o�s sfiicl, TAis Dro�is�on does nol apPlY lo syslams in sAorelan0 aress, We!lneo0 profCClion Areas,or lnore�.veC�r�;�n+;r�•�,;:: ,.. _,_ oeve�age, ana looqing eslenrr'snments as oerned in lsw, ._ . ....._._, e. � � , � - • - --... 08/19/2011 13:55 9528733112 PAGE 02/05 parcel nurnber: �___� � ~~~~—�-----�," System status: Compliant fas deterrnrne��s� ❑Noncor►�plian! Nydraulic Perfo� °'�'� Cornp�fance Issue #� f e and Other Cor„p��a�� Date of observation: � , This form expires upon ne�ct ins Reason for vbservation: �_. � P�tion or in three yrears� yyhichever p��t �ampilance questions/criteria: iRequired) Check the a ri$re� Verificatfon •. ` '- — Ooes the system discharge Sewa9e ro mQ Method . (Optionaq . round surface? (]Yes � No (�heck tha epprnpr�ete 6ox) Does the system discharge seuva e to drdin �e'�ed For su�Face outlet tile or surFace yyaters? 9 ❑Yes No � Performed hydraulic test Does the system cause sewage backup �ea�ched for seeping in yard Into dweilin or establishment? Q Yes N� ❑ Checkad f�or backup in home Do other situations exi�t th�t have the � ��essive pcnding in so1l system/D-boxes potential to immediately and adversety ❑Yes No impact or threaten public health or s�fety ❑ Homeowner teSNmony e�ectrlcai, �nsafe covers etc.? ❑ Examined fi�r surgirig in tank Any��yes�arrswe�/ndlc�tea that the systenr/s an lmminent ❑ "B�a�5011"above soil dispersal system threat fo publlc hea/�h and safety, ._ a System nequlres'emergency'pumpEng Does the system pose a threat b ground � P��o�ed dye test water for any conditions deemed non- ❑Yes Wo �utective as determined b the in n ❑ Other: _ _ _ _ ____ � �^ "Yea"indicates that tlre syslern/s�a/�ir�g ro p��ct -- ground water. !f'�nes'; describs the condrt/on noted: � ',�:. — .—..— _... .. -�---� *No standard prctoco!exists. This list is Rot exhaustive, in sequenlial order,nor does it indicate which -"� � comb;nations sre necessary to make this determinafion. Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compltance Inspect�on Form for Existing Sub:urface Sewa�e Treatme�t Systems.Observations,interpretations,and conclusions must be completed by an inspector. Completed form m at be submitted to the Iocal unit of govemment within 1S days. � Properry owner name(s); Property address: —' --.---.— •-•- .._. � Property owne ' addr�ss(If difFerent): —�—� ---• County: Phone: I hereby certify thaf!personslly made the observatians,inferpretations, and concluslons neperfed q�this lorm and that fhey are r.orrect, Vame: �1 G�1 p�,� ` Certification number: �� 3usiness license name and number; � --- . � �ame of local unit em . _ or � t: ••-- ignature: � Date; �vwrscs4-31 08 Comp(iance/nspect;on Forrr, fnr��«:.,,. «TM 68/19/2011 13:55 9528733112 PAGE 03/95 Parcel number: `^ _� System status: rnpliant ❑ Noncompliant (as determin�form) Tank Integrity and Safely Compliance tompliance Issue # of ' Date of cbs�rvation_ �I Reason fn�observation: _r. This form expires on(three yea�s): L ----•.---- Compliance questions/criteria: (Required) Vet'ification Method": (Optiona�) �Check fhe a ro �afe box (Check the appropriate box) Does the system consist of a seepage pit', ❑Y�s �lo ❑ Probed tank bottom cess ool d ell,or leachin it? � � Do any sewage tank(s)leak below their ❑Yes No ❑ Observed low liquid level designed ope�atinq de th� ? _ � amined construction records If yes,ideMify which sewage Examined emply(pumped)tank tank leaks. � Probed outside tank for"black soil^ Any'yes"answer!ndlcafes that the sysfem!s falling!o profect ground water. • ❑ PfesSure/vaCuurn Check ❑ Other. ' Seepage pits meeting 7080.2550 may be complient iF allowed "w in ordinance by local permitting authority. "*No standard prorocof exists. This/isf is no�exhausfive, �n sequanflal order, rror does!f indica�e which combinations ere necessary to make thrs deferminatian. Safety Check � 1. Are any maintenance hol�covers damaged,Cracked,or appe8red to be structu�ally unsound9 ❑ Yes" �lo Z. �Nere all maintenance hole covers�placed In a sec�red manner(e.g.,al1 screws replaced)? �es Q No' 3, Was secondary access restraint present(safely pan,second cover,o�safety netting)—highly recommended. ❑ Yes �lo 4. Was any other safety/heatth issue presant7 . ❑ Yes' �No � Explain: 'System is an imminent thr+eaf i'o publlc health and safery. Certification This form is to be completed and aitached bo the Summary Form of the Minnesota Pollutlon Control Agency's(MPCA)Cornpliance Inspection Form for Existing Subsurfsce Sewage Treatment Systems.Observations,inlerp�etetions, and conclusians must be completed by an Inspecto�, maintalner,or servfce provider. Gompleted form must be subm�tted to the�ocal unit of governmant within 15 days. �^ C Property owner n8me(s : __. ____ Property add�ess; � r_ _ _ Property owner' address pl diiferent): � CouMy� __ Phone: _. I hereby certify th�t I personslly made the observations, lnteipretations, and conc�usions reported on this Fvrm and that rhey are correcf. � Name; ��(�,�j, � J.�P�ll V Certification number: �(p�__ _______ 6usiness license name and number: ri�,�� _ ___. .. , o� Name oi local uni overn nt: Signature: Date: wq-wwisCs4- Compliance lnspect on Form jor Exisiing SS7'S 98/19/2011 13:55 9528733112 PAGE 04/95 Parcel number: ___ _ System Status: Compliant ❑ NonCompliant (as determine y is iorm) Soil Separation Complia�ce and Clther Con�pliance Compl9ance Issue #3 f 4 � Date of obseNation: Reason for observation: ___� _.. This infvrmation on this fo does ot expire. �� Compliance questionsJcriteria: (Required) Verification Mathod": (OpGonai) Check the a ►n riate box (Check the appropriate 6o:J For systems built prior tv Apri11, 1996, and not Conducted soil obsen►atlon(s)(attach boring logs) located in Shoreland or Wellhead Protection Area or not serving a food,beverage or ❑ wo previous verificatlons(attach boring Icgs) lodging establishment: ❑ Other:�-ap� �� gJ��y� Does the system have at least a two-foot �,�^ � vertical separation distance from period(cally a �� saturated soil or bedrock? ❑Yes No For non-performance systems built Ap�l 1, T 1996,or later or for non-peiiormance systems "" i �"'� � located in Shoreland or Wellhead Protection 5oil observation does not expire. Previous observations Areas or serving a food,beverage or lodging by two independent parties are sufficient,unless site establishment: co�ditions have baen eltered, Does the syst@m have a three-foot vertical separation distance from periodlcally saturated soil or bedrock?' Yes No For reduced separation distance systems (i.e_, `performance"systems under old 7�SO.Oti?9 ar ' May be reduced by up to t 5 percent rf a0owed in local Type IV or V system under new 7080. 235o or ordinance. 7080.2400); •'No standard profoco/exisfs. This/ist;s nof exhaustive, Does the system meet the designed vertical in sequentia!oMer,nor does if iRdicate which separation distance from periodically saturated combirratlons are necessary to make ihis soil or bedrock?* � Yes No delerm/natlon. Any"no"answer indicates that fhe system!s/ailing to proteet ground water. Certification � � This forrn is to be completed and attached to the Summary Form of the Minnesata Pollution Control Agency's(MPCA}Compliance Inspection Form for Existing Subsurtace Sewage Treatment Systems.Obs�roadons,interpretations, and conclusians must be completed by an inspector or designer.Completed form must be submitted to the local unit of govemment within 15 days. Property owner name(s • ��_ � ___ __.__ __. Property address: �,� �_... -�� ----- .,.-•---- Property owner's addres5(if differenty: _, „�M---- --- -..... � County; ��,j/1,/�f ,..._ Phvne: —.._. .. ,_._._. I hereby certify that/personally made the observatrons, rnterpretatlon�,and conclusions reported on this form and that they are correct, . Name: �4� Sc n��lU'I� carti�icaqon number; �tv_5�_ ___ 8usiness license name an number; �]�,)j,�_�-V�(¢�` j��,a`rjQ� . _ _,_ or Name of local unit of ent; Signature: � Date: ! � �/- --- --.. wq•wwists4•J Comp(iance lnspection Form for ExistinQ SSTS 08/19/2011 13:55 9528733112 PAGE 05/05 . �uQ-1T-2011 iZ:38pm Fram-CITY OF ORONO +9S2Z4A4818 T-1Z8 p.0oz/�02 F-348 C. � I [ e � � � gec�r�rom �- �UUY� f� ��`' I� �� I� ��, � �� _ a�� ,D �� yr�r Irn° f+�' � °2 L�,' � � MN , 50" 7S � , . � M1�a �� $ MK �'3 � �a / 3 . � � � � � HouSe , � � � � ' bqr�c , 4 � �o �� 0 . � Q �� • �L P � P LL _ �� , ��°� �Il°��' 9 -�$ -�03 � °� o : o � :��=��,:��- , CITY of ORONO ,� � ,��f�=. � �,� � �x:-:�,. � ,� " , , t ��^, � ��, Municipal Offices ,\"� `�?.� �,:- � � �.:• . ,:._ \ ' �,; �+ �' �' G � Mailing Address: � .�r+� / Street Address: �lSd.-a49—�bo O ��'q�'`�.F"��p'g'�� 2750 Kelley Parkway P.O. Box 66 �ESI��% Orono, MN 55356 Crystal Bay, MN 55323-0066 To Current Owner: Address: ��S /'�l r�v f I�'� '(z � 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. SYSTEM CONFORMITY (1-3): 1 1 "CODE SYSTEM"An ISTS which meets all the location,design and construction standards of the current Orono Municipal Code. 2 "COMPLIANT SYSTEM" An ISTS which does not meet all the location,design and consiruction standards of the current Orono Municipal 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 iffmminent threat to public health or safety. 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 construction standards of the current Orono Municipal Code and which is failing for eny reason;and any ISTS with less than three feet of unsaturated soil or sand between the distribution device and the limiting soil characteristics. TANK CONDTTION(5-7): � Tank inspection indicates: 5 Pumpout not needed at this time. 6 Septic tanks must be pumped out this year (city code recommends tanks to be pumped out once every 3 yeazs. Tank was last pumped ). Make sure septic tanks are pumped throu¢h maa6ole and not throush white inspection pipes. T6is allows for the proper cleaninS. Keea�vater softner and iron f lter discharee out of seatic svstem to prolon¢life of drainfield. Ask pumper to test alarm float to verifv alarm is still workin�in vour house. The alarm warns owner that septaee is about to backup into basement. 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 yeazs,they should be pumped out now. DRAINFIELD CONDITTON(8-101: � 8 Drainfield 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: 'a ��,�.�, . � �. Date of Inspection 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 tfiis report does not guazantee or certify that an existing system will continue to function properly, but is merely an opinion of the adequacy of the system under cuaent ,�, � �� , � � r i��j�e+i y, � �.• z � �� w�_ �<R .�� F t �� .�*� ,� -�.�a � /� �'� �`�'.� . :.-a ""._� 4.,f.a`4,�.� 'az+�"a, " � � �,,,:�� "� �' � "�.�" f- '� `y� i , , � � ` � � � � •�' � ?��` � A;� �� . r ;� ,r. � �,; , �"� :� . �`� � '� � � ' � �"`�� .��`� } �� ,� t , � . , � � " .. � ��. � � ,'`- . ��, � *�� ^f ,f;> "i �`_ ��..-.� �� . lr�`�j�`��'a � -o : '�� '._� w `s�� -„�'�� e vr��.... �` �i.. •,• � _.'",�•� '��. y�, ' �t A�� . ��i -_ ' 4�� .�,• e � :g Y. � ',�� tiy4�'..i . R ,r" 4 ��.:.. S.i'�.`�y�,.,."`.� � "vw4,,��i��. �k .z1�".,r�° .'�E«� ^ ' ��<�� 's "' a^"�` w. 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