HomeMy WebLinkAboutseptic info L/L]/VL VVGIc�/vvaa�crvo�u 1.JIJ��J1
� i
,�� Compliance Inspection Form for Existing Minnesota Poltution
i.,.��r4� Individual Sewage Treatment Systems Control Agency
�.r
Comp�etlon of this form fulftlls the minimal requirements of�Minn. Stat.§ 1 J5.55(2001)and Mlnnesota R. ch. 7080(199�. Please refer
to local ordinances ior other ra uirements or informatlon,es eciall for com liance re uirements for bedroom additlons.
Gene I:
Date of Inspection: Reason for inspection: a �
Property�wner(s) lN �G✓l 'Telephone ( )
Person requesting inspection i Telephone ((�!�) �SO - 7�3p
Site Address
✓� �, � City �/�Dl2� Zip Code �6
Fire No./ Parcel No. County�� Township
Legal Description
Lucat Regulatory Authority
Date system constructed ? P�r� rn_�o 14Q�p5ystem in Shoreland Area: yes(�2 System in Wellhead
Protection Area: yes � System serving a MDH lice�sed facility: yes � Locat Permit # (if any)
Systems built prior to Apri1 1, 1996 and not located in Systems located {n Shoreland or Wellhead Pratection
Shoreland or Wellhead Protection Area or 5erving a Food, Areas or Serving a Food, Severage or Lodging
Beverage or Lodging Establishment Estab(ishment, or systems Bui1t after
March 31 1996
Is the svstem an imminent threat to nublic health or �.s the svstem an imn�inent threat to oubfic health
safe ? (a yes answer is an 17PHSsystem) or safetv? (a yes answer is an ITPHSsystern)
-Discharge of sewage to the ground surface? YES 0 - Discharge of sewage to the ground surtace? YES NO
-Discharge of sewage to draintile or surface waters? YES - Dlscharge of sewage to draintile or surtace waters?YES NO
-Sewage backup into dwelling? YES -Sewage backup into dwelling? YE5 NO
-S(tuation with the poten�al to immediately and -Situation with the potential to immediately and
adversely impact or threaten public health or adversely impact or threaten public health or
safety? YES � safety? YES NO
is the svstem failina? (a yes answer is a failing system) Is the svstem failina? (a yes answer is a failing system)
-Less than TWO feet of vertical separation between -Less than THREE feet of vertical separation between
system bottom and saturated sofl or bedrock? NO system bottom and saturated soil or bedrock? YES NO
-A seepage pit,cesspool, drywell, or leaching pit? NO -A seepage pit, cesspool, drywell, or leaching pit? YES NO
Is the svstem non-comaliant? Is the svstem non-cort�atiant?
- Is the system regulated under a monitoring plan or - ts the system regulated under a monitoring plan or
operating permit? (if no,go to page 2) YES � �perating permit? (if no,go to page 2) YES NO
If yes, If yes,
-Has the required monitoring taken place? YES NO - Has the required monitoring taken place? YES NO
(If no, tha system is non-complying) (It no, the system is non-complyingJ
-Does the m�nitoring indicate that the systern meets - Does the monitoring indicate that the system meets
performance expectations? � YES NO performance expectations? YES NO
(If no, the system is non-compiying) (1f no, the system is non-complying)
Page 1 of 2 wq-wwists4.31
, ___ � . .. .,,,,., ni�nroamc usor e9� �90 90 6i i�C
• y
Site Sketch:
._ . ;.. . .. . ... ' r :..i..,�, �. ' .. . � ..±.. .; : ' .. . .. ' . .. ,
, .l. ..;.. ; ;p . . ' . i. . ' .. � . ; .. � . .. . `• ...�;... . ..
, .1` . .. ' ��`'� �`... . .. . . ' , . . ' .. ' . .. .. ;.. ; ; . .
. �� •, � .�i.. . I � . . J�•. . .� . .. , l.. . .. 1�..•r ..�. , .
, � � •V� .'. �j.. .1.. �. .�f.. -r. . �: � .i....� . .�... ...�... .... r
. . . . � : �.�.. •� . �: � l... .. ! „+f � ..��.. . . : .. ,
.. . . �1 . �. r • � ` '����^ r I r' ..J.•. . i...1f ,. .. ..' .. ..' +... � ... . ..
, �.. j ...1.. .l. .. . .��• . ` . �� � .•r . ..J�� .. . r' ..� . . . ..
! ...•� .� f ..ti. .: •r • �.} . , . .� . ..}..
. ' ..1. ' :�. ;d % ...,� ..';.. . ,.;;... , .. . too�
: � •.� � ; , : . :r. . ..` ..;... � �o� 20�
.. . �.,..: . Q;��•• ..� , s , .. ..;,... . N
; , . � : �;; . . . � .. � . ;;.. .; ..;.,,.+ �;���
. � .. . .. . .. . ;. ; .. . .. . . � . o
, � . ; ;
Plense indicatc thc loe�tion of: Wcll,re�ell setUack to s}�strm,dwelling or�thet ectAl+li3kuncsit,tank(s)•soil lre:i�icnt s��stem,
rese�rotd coil lctAlment area,curtain drain,prupZrl)'IinEs,���ntccways,and buried lines (those NOX ifl5tplled by the utilih�).
Include s.izex aud lengrh and approrimatc di5tancts froit�fi.eed refcrrncc poii�ts such 0.s slrcets and buildings. Ple�s�attach as•
built dra�ving�,inspecei�n re���rts,Cartificat(s)of Compliance nndNoticc(s)ofNoiicomplit�nce,if�lvailabl�.
Soil B�rings (BXt#): Locat.c each boring oz1 the tuap�bove,indicate on the righl o�t��e column th�soil
texture, structtue, color, dept��of each different soil type, evid�ncc of mottling,hedrock and st�u�ding v�at�r.
Also i�ldicate if the material is �'ill,
B # BR# B�i# BR# B�# BR#
,
�� ���
►�'t, 3 f3 '��,,,�--
l�
y�,� ��w�,�
�
Op '�
�u�
l�GS'�
�y
,
��
��,' RL•C(7RT�DEPTH�F�dl7TTLING,5EASONAL 111��Y�W A'1'�R OR BEDROCIi01�nDOVE Li�11:S
Cnmments: --•
«'hat nceds to I��compizted t��briilg tl�e�tbove Sy'stem int�i ci�m�+liancC if found not in compliancz?�_� ` ���
!��5�5-I-evtn-- -
, . _� ���� �-, o ���o, ounraamS Uso� e9Z �90 90 6T i�C
rropC��y vw�«���� ..- •--•� - ----- •--
� ....�._�.............._........_....._._...._.__......._._.........,M._...._._.._.,......_.._.._.................�......__......_......__.........,..._.._.._..__�....._.�...._........_.......,,......__.._......_..ti_._
Sy�em Comnonents (Please describe the system components and attach slte sketch showing system locat/on):
— � f'�
�
What methods were used to make th determinations tor the comaliance insoectioo? (Note:No standard protornl exlsts.
The following list is not exhaustive, or In sequential order nor indicates whlch combinahons may necessary to make a determ/nation)
Watertight tank(s) Hydraulic Functianing Vertical Separetion Distance
� Probed tank bottom � Searched for surface outlet � Gonducted sall borings ��,1
❑ Obseroed low liqu(d levei ❑ Performed hydraulic test Depth to Iimiting layer
p Examined canst. records � Searched for seeping in yard Depth to system bottom
3g ''
� Examined empty(pumped)tank ❑ Checked for back-up in home ❑ Examined reco�ds
❑ Probed outside tank for"black soil" o Excessive ponding in soll system/D-boxes ❑ LGU Limiting Layer Verlfication
❑ Pressure/vacuum check ❑ Homeowner testimony O Other
O Other � Examined for surging in tank
❑ "Black soil"above soll system
'��,C, '�'av►k — ��� ❑ Other
tus of the s stem
Based on the c�mpliance criteria,the system s tus is: (check one)�failing (to protect groundwater) ❑ an
imminent threat to public health or safety (ITPHS),�non-compliant(monitoring issue) ❑ compliant(none of the 3
previous condifions). Therefore,this document is a: ❑ Certificate of Compiiance �Notice of Noncompliance
is this system an EPA Class V Injection Well? ❑ yes no
Certification
I hereby ce�ify as a state af Minnesota licehsed Inspector and/or Designer I or Qualified Employee Inspector and/o�QualiAed Emp(oyee
Designer I that I conducted an invesdgation that accurately determined the compliance status of this system and that my recorded
observatlons are accurate as of thls date. No determinatlon of futu�e hydraulic pe�formance has heen nor can be made due to
unknown conditions during system constructinn, abuse of the system, inadequate maintenance,or future water usage.
Inspector's name (print) ]05H SWEDLUND Phone " 73" 3
Ucense and/or Registration Number 25�2 Address � � �' a��- `S�'
Employed by � �✓� �u � Address ��— - / --
Signature Date�Q ( _
�Iparade Requirements jder/ved from Minnesota Statutes§115.55)
An ITPHS must be upgraded, rep/ace�d,or its use discontinued within ten manths of receipt of this nodce or w/thin a shorter period!f
required by loca/orr/inance. If Che system falls to provlde su�cient groundwater protection, then the system must be upgraded,
replaced, or its use discontinued within the tlme required by rule or the local ordinance. If an existing system is not faIling as defined in
law,and has at least two feet of design soil separad"on, then the system need not be upgraded, repalred,replaced, o�iks use
discontinued, notwithstand/ng any local ordinance that is more strict. Thls does not apply tr�systems in shore/and areas, wellhead
protection areas, or those used in cnnnection with food, beveraqe, and lodging establishmentr as defrned in law.
Suaaested Attachments
1) Site sketch could also include: well, weq setback to system, dwefling or other buildings, tank(s),reserved soil treatment area,
surtace water and soif boring locat(ons, Inciude as-buiit draw(ng if available. �\
2) Soii boring logs, showing each horizon. Indicate the texture, color, redoximorphic features depth to bedrock,standing water and �
whether the material is fill.
3) A list of any and all requirements oF the local ordinance that are different from the state requirements referred to on this form. �
4) A homeowner survey of system performance, signed by the homeowner as being factual.
5) Monitoring data as appropriate.
� Page 2 of 2
� •.� �c�c_c� araca� punTPamS NsoC e9Z =90 90 6T inC
,_ __.__...
� o�
;
' �\
,%�O O \'�
' CITY of OIZONU
� ��,�
�
�� � : ,. �,�;
�� ; �,-' Municipal Offices
�� �
,\,� � , �
``` � ' �' ''`° G '� Street Address: Mailing Address:
�`qxESxpg'� 2150 Kelley Parkway P.O. Boz 66
. -
- - Orono, MN 55356 Crystal Bay, MN 55323•0066
To: The Current Owner of Address Z' � �' �d �'����^ �f� TJ�- C�.� �
City Ordinance requires that onsite sewage treatment systems in Orono be
inspected on a periodic basis. The onsite sewage treatment system at the above
address has been inspected and the following is known about the system. A
sketch of the known components of the system is available for most properties at
the Orono City Ha1L
Imminent Public Health Threat
Yes �No
If yes,please contact the Onsite Systems Manager at 952-249-4626 within 10
days of receipt of this notice. The septic system must be brought into compliance
within 90 days. Failure to do so will result in referral to the City Attomey for
legal action.
System Identified as Non-Compliant
Yes �No
If yes, system must be brought into compliance by:
December 31,2007
December 31,2010
Other
Septic Tank(s) Pump out Needed
Yes �`
No
The City recommends the septic tank(s) and/or lift tank be serviced and pumped
out every three years. City records indicate the tank(s) were last pumped out on
�— �� �3 . The tank(s) should be cleaned through the manhole and
not through the inspection pipes, this allows for proper cleaning.
Comments:
,�� {
Inspecto�,�� � �� ��`��e=; Date of Inspection 1 l - 6 �
Tel�phone(9�2)249-4600 � Fas (9�2)249-4616
ww�w�.ci.orono.mn.us
_ __._____. _
O �
� �
O. ?��� O _
�.� --� ,� � c�TY of o�oNo
.� � �
�', � � ��.^ ,� Ntun;cipal off�s
�� � �G SVeet Address: . MaNiag Addross:
`�Cy�g�O�' 2750 Keiley Parkway P.O. Box 66
Orono, MN 55356 Crystal �ey, I�MI 5�323-0066
— -_ --------- - __ _ _ ----- _ _..
_ _ . �'6�d0 Ndf-}�, J4rn. �� 1�v
Tc�Cu�'e�.t�: Address: �
City Ordinance 199 requires that each existing on-site sewage treatment system in Orono be inspected�every two years.
The on-site sewage treatrnent system a#the above address has been inspected and appears to fall into t�e categories checked below.
SYSTEM CONFORMIT'Y (1-3): �
1 "CODE SYSTEM"An ISTS which meets all the location,design and construction standards of the ciurent Orono Municipal Code.
�"COMPLIANT SYSTEM" An ISTS whic6 dces not meet all the location,design and construction standards of the current Orono Municipal
Code but dces meet the tivee foot separation requirement or two foot requirement for systems installed 1996 or earlier,and which is not failing or
an imminent Uueat to public health or safety.
3 "NON-COMPLIANT SYSTEM" A prohibited ISTS;an ISTS locaked within a designated 100-year 800d plain,any ISTS wfiich may
or may not meet all the location,design,or construction standards of the current Orono Municipal Code and which is failing for any reason;and
any ISTS with less than three feet of unsaduated soil or sand between the distribution device and the limiting soil characteristics.
TANK CONDITION(5-7):
Tank inspection indicates:
� 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 �-9-0 l. - '
Make sure seutic tanks are uumued through manhole and not through white inspection piaes This allows for the
proaer cleaning. Keen water softner and iron filter discharge out of septic sy`stem.
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.
D� INFIELD CONDIT'ION �-10 : �
8 Drainfield is dry,no surfacing evident.
9 Some evidence of surfacing,not crirical yet.
10 Drainfield is satura.ted and visibly discharging untreated effluent to the surface. Contact the City Inspector
immediately.Repairs must be compieted within 90 days.
CONIlVIENTS: �r��•�t1� �-- Scp�,-` �,�C,S I 0 0� d�,
�-z�-�� . ��-/�L�
Date of Inspection Matt Bolterman- Septic System Inspector
•In the event that�is i�Oction report is used to satisfy the requirements for a mortgage or other transfer of property,be advised that tl�is report ioes soi�ee
`ty f�at a exi�isg ay�esi will continue to function properly,lwt is merely an opinion ofth�adequacy ofthe system under aurent conditio�§a�od v,lhe av�abte
ti�.
1i�lepLone(952)249-4600 • Fxz(952)Z49-4616
vvww ci.orono.mn.�
� o�
O�':`:� O
����=?=� CITY of 4RON0
. �
,� ��j������. �►
r����.'�.�:,"+� ,�l�r Muntcipal Offices
I
�1;:���a�;�► G
,,, ,�;Og� Street Addross: Mailin�Addreu:
Egg 2150 Kelley Parfcway P.O. Box 66
Orono, MN 55356 Crystal Bay, MN 55323-0066
Owner: �c G c1��� S w��S 0� Address: �6��0 N- A« 1��. w ,
Cin•Ordinance 199 requires ihat each existing on-site sewage treatment system in Orono be inspected every hvo years.
The on-site se«�age treatment system at the above address has been inspected and appeazs to fall into the categories checked belo�v.
SYSTENi CONFORNIITY (1-3): �
1 "CODE SYSTEM" An ISTS which meets ail the locatioq design and cocutcuction standards of the cuaent Orono Municipal Coda
L� ��CONfPLIANT SYSTEM" An ISTS which does not meet all the locatioq design and construction standards ofthe cunrnt Orono Municipai
Code but does meet the three foot separatioa requirement,and which is aot failing or an inuninrnt threat to public health or safety.
3 "NON-CONIPLIANT SYSTEM" A prohibited ISTS;an ISTS Located within a desi�tated 100-yeu flood plain,any ISTS which may
or may not meet all the locatioq desi�,or caastruction standards of the cutretrt Orono Municipal Code and which is failing for any rea�on;and
any ISTS with less than three faet of unsaturated soil or sand between the distribution device and ihe limiting soil characteristics.
T.aNK CONDITION(5-10): �o
Tank inspection indicates:
� Pumpout not needed at this time.
6� Tank must be pumpad out this year (city code requires tan(cs to be pumped out every 3 years. Tank w�s last pumped �-�� -9 6 �
7 Solids accumulation in tanks is at a critical a critica!level. Tanks should be pumpad out as soon as possible.
8 Systecn is discharging to tha surfa�:e. Tanks must be pumped out within 48 hou�s to eliminata surface discharge.
9 Itupection risers missing-tanks could not be inspaccod Inspection risecs(4"dia pipe)must ba instalted in each tank at next pumpout If tanks
ha�•a nut bean pumped out within the last three years,they should be pumped out now.
10 InspeMion pipe is located directly over tank baffla(does not give accurate measurement of solid4 accumulation). If tanks have not bern pumpad
out within tha last three years,they should be pumpad out now.
DRAINFIELD CONDITION(11-14): \�
11 Drainfiald is dry,no surfacing evidrnt
12 Soma e�idance of surfacing,not critical yet ,
13 Ikainfield is saturated and visibly discharging untreated efflurnt to tha surface. Contact the City Inspector immediately.Rzpaus must be
compleud withirt 90 days.
1� Draintield e!ctant and condition unknown.
COVIl�IENTS: 5 ySfie� `o o\�S O l� - 1��n.p 'ra�`(�5 i�- �'�•e.� ��qve
�or
�� Mo�� �,..:�1►.=� �a.s�- 3 �Ie�.�S � P�� �ove� o�. ��SQec,�t-;o^
,
�p-.�e.- -
� �6- °� �a�.. �
Date of Inspection Septic System Inspector '
evrnt that this ir�spection teport is used to satiefy the requirements for a moRgage or other transfer of propeRy,be advised that this repoR doa aot guarantee
.c an tsisting system wili continue to function pmprrly,but is merely an opinioa of the adequacy of the system unda cutrrnt conditions based on the available
..uoa
. =0 ` �`�
, � 11�'\,
�� o � o �;;
� �� CITY of ORONO
, �
�
�,�'�,a, �� r�.� _. �►,,
��, � a�� '�� � �ti/% Municipal Offices
�� ' � �` ��� G ,
��� ,��ti��,��.� ,j Street Address: Mailing Address:
�'��,, Egg ;.�' 2750 Kelley Parkway P.O. Box 66
'-- —" ' Orono, MN 55356 Crystal Bay, MN 55323-0066
,. ���� �'d,
June 18, 2007 ��'�
Myron &Patricia Westfall
4680 North Arm Drive W ,
Mound MN 55364 , '� '
�
� � - i
, _ ,, ' - ,_
Dear Mr. & Mrs. Westfall: - �
I am writing in regards to the required septic system upgrade for your property, tax parcel
number 06-117-23-23-0006. As you are already aware, the existing septic system for the
house is not up to code. This was determined by a compliance inspection done by Josh
Swedlund on July 18, 2006. The septic system was to have been updated by May 18,
2007.
Please make arrangements with the required professionals, a designer and installer,
immediately, so that the septic system can be brought into compliance. If you have any
questions concerning this matter, please fell free to call.
Sincerely,
�.����.� �sz��
�
Willie Gibbs
Inspections
Telephone(952)249-4600 • Fax(952)249-4616
www.ci.orono.mn.us
, printdetails.jsp Page 1 of 2
Parcel Data for Taxes Payable 2007
Property ID: 06-117-23-23-0006
Address: 4680 NORTH ARM DR W
Municipality: ORONO
School Dist: 277 Construction year: 1955
Watershed: 3 Approx. Parcel Size: 140 X 278.15
Sewer Dist:
Owner Name: M WESTFALL & P R WESTFALL
Taxpayer Name MYRON A/PATRICIA R WESTFALL
&Address: 4680 NORTH ARM DR W
MOUND MN 55364
Most Current Sales Information
Sales prices are reported as listed on the Certificate of Real Estate Value and are not warranted to i
arms-length transactions.
Sale Date: July, 2006
Sale Price: $495,000
Transaction Type: Warranty Deed
Tax Parcel Description
Addition Name: UNPLATTED 06 117 23
Lot:
Block:
Metes & Bounds: W 140 FT OF E 567.86 FT OF S 311.15
FT OF SW 1/4 OF NW 1/4 EXCEPT ROAD
Abstract or Torrens: TORRENS
Value and Tax Summary for Taxes Payable 2007
Values Established by Assessor as of 7anuary 2, 2006
Estimated Market Value: $490,000
Limited Market Value: $490,000
Taxable Market Value: $490,000
Total Improvement Amount:
Total Net Tax: $3,994.37
Total Special Assessments:
Solid Waste Fee: $76.97
Total Tax: $4,071.34
Property Information Detail for Taxes Payable 2007
Values Established by Assessor as of January 2, 2006
Values:
Land Market $165,000
Building Market $325,000
Machinery Market
Total Market: $490,000
Land Limited $165,000
Building Limited $325,000
http://www2.co.hennepin.mn.us/pins/printdetails.jsp?pid=0611723230006 6/12/2007
, �,rintdetails.jsp Page 2 of 2
.
Total Limited: $490,000
Qualifying Improvements
Classifications:
Property Type RESIDENTIAL
Homestead Status HOMESTEAD
Relative Homestead
Agricultural
Exempt Status
http://www2.co.hennepin.mn.us/pins/printdetail s.j sp?pid=0611723230006 6/12/2007
L/L7/VL vra►a/vvao�crva�c� a.+�..+���i
� i "i
. � Compliance Inspection Form for Existing
Minnesota Pollution
Individual Sewage Treatment Systems Control Agency
Completion of this form fulflUs the minimal requirements oFMinn. Stet. § 115.55(2001)and Mlnnesota R. ch. 70B0(199�. Please reter
to local ordinancss for other ra uiremente or information,ea eciall for com lianca re uiremants Far bedroom additions.
General �� � � � ►��� ,
Date of Inspection: Reason for inspection: � �
Property Owner(s) GV 7elephone ( )
Person requesting inspection ' Telephone ((�l�) $sd" 7�3p
Site Address ✓f�► K2 � � City l'/'�Dl�l D Zip Code �6
Fire No./ Parcel No. County �r1n i� Township
Legal Description
Local Regulatory Authority
Date system constructed � �r� r q(pS�►stem in Shoreland Area: yes� System in Welihead
t
Protection Area: yes � System serving a MDH licensed facflity: yes � Lccal Permit# (if any)
Systems built prior to April 1, 1996 and not located in Systems located in Shoreland or Weilhead Protection
Shorefand or Wellhead Protection Area or Serving a Food, Areas or Serving a Food, Severage or Lodging
Beverage or Lodging Establishment Establishment, or systems Built aRer
March 31 1996
Is the��r��^ �^ i^�minent threat to nublic heaith or Is the�stem an imminent#hreat to oublic health
safe ? (a yes answer!s an ITPHS system) or safetv? (a yes answer is an I7PH5 system)
-Discharge of sewage to the ground surface? YES 0 -Discharge of sewage to the ground surtace? YES NO
-Discharge of sewage to draintile or surface waters? YES -Discharge of sewage to draintile or surtace waters?YES NO
-Sewage backup into dwelling? YES -Sewage backup lnto dwelling? YES NO
-S(tuation with the potential to immediatety and -Sftuation with the potential to immediately and
adversely impact or threaten public health or adversely impact or threaten public heafth or
safery? YES � safety? YES NO
Is the svstem failin4? (a yes answer is a failing syst�m) Is the svstem failina? (a yes answer is a fail/ng system)
-Less than TiNO feet of vertical separaaon between -Less than THREE feet of vertical separation between
system bottom and saturated sofl or bedrock? NO system bottom and saturated soil or bedrock? YES NO
-A seepage pit,cesspoo{, drywell, or leaching pit? NO -A seepage pit, cesspool, dryweli, or leaching pit? YES NO
Is the system non-comaliant? is the svstem non-comatlant?
- 1s the system regulated under a monftoring plan or - Is the system regulated under � monitoring plan or
operating permit? (if no,go to page 2) YES � operating permit? (if no,go to page 2) YES NO
if yes, I f yes,
-Has the cequired monitoring taken place? YES NO - Has ihe required monitoring taken place? YES NO
(If no, the system is non-complying) (I(no, the system is non-complying)
-Does the monitoring indicate that the system meets - Does the monitoring indicate that the system meets
performance expectations? YES NO performance expectations? YES NO
(If no, the system is non-complying) (11 no, the system is non-complying)
Page 1 of 2 wq-wwists4.37.
t •d z6ZE-ELB (ZS6l puntpamg ysor e9Z �90 90 6T I�C
• w t
• � , Site Sketch:
.. ' . .. ' . .. . .. . .. .. . . . ` . . s` - - - . • - . . , .
. . ' . . ... . . ' , . . . ..; . . . .. . .. . � .. .
. .. � . .. ,C`""�!.� .. . .. . . ;;. . .. . i... .. . .. � . . ..
..��.. .. . 'r . . . .. ' . . � . .. � ..r... . .. . . . , .
' � ,�.. ';•;•.�.. � :•1 : , : .f'•: • . . , .;... _ .. .�,.. :... . ;
. ' . . � '„%,,a � . , i. . . f .. ! _ .. . { . . <:.....?... ...... ;
• `• \�� r' • i ' +' ' � . .
. .. . �. r ����.. '. ,.�.. .. . . . .- . .. � .. . ..
. . ...�.. ..�. .!,/7,- . � . .. , . . � - . . � .. . ..j . .. . .-
t ..��� . . �. .� �; . ..S . . .. . . .
' ' ,i, id '+ .,,,� , '� . . ,.;;..._, . . l00'
.. .. . . .,. '� ,_...:. r '• f ., ...r.' . .. ._;.. t0' 20'
' . f. �`��,,,�.. ,.�; . . , .. . . . :f. N
; . , � ; ` . . . : .. � . . .;... ,..f w�i�
. .. . ' .. . .. . ;. .. . .. . . .r . p
, ' . �
Plense indicate thc loe�tion of: Wcll,�r�ell Setback to��slem,dwelling or other establislunait,tank(s)•soil trr.i�lcnt system,
reserved c�ii�lreatmcnt azca,cuttain drai�i,propZrl)'linos,��•ntctwa)'s,and buried lines (those NOI'installed by thc utility).
Include s.ize�and len�rh and approximate distances f.rorn fixtd rofcrencc points such as shrrts and buitdln�s. Pleas�attach as-
built dra�ving�,inspection re�iorfs,C�tificat(s�of C:ompliance nnd N�ticc(s)ofNa�complirtnee,if alvailable.
Soil Bo,•ings (B�t#): Locatc eaeh boring oix the map above,indicate on the right o£t��e coh�m.n th�soiI
texcure,structwre, color, deptl�of eacl�different soil type, evidence of motding,hedmek�nd st�u�ding v�•atcr.
Also xa.�dicate if the materi�l is fill.
� # BR# BR# BR# BR# BR#
?���` 'oa�`
t��� ,M-
��,, 3J3 ��a
yj� ���,�,�
�ON
�u�
l��S'�
yy
�
�
� RTCORD DEP7H OF NIt�TTL1NG,SEASONN..1�ICi,W A'1'�R OIZ BEDROCROh ADOVE LNIsS
Cnmmrnts• --
«hat nccds m U�co �pleted to bring q�e�bove sy�tem inTu c�7mplisncr if found not in compliance?�� � ' '"�
�11� �ys vw.
_�-
Z 'd Z6z£—EGS (ZS6l puntpamg yso� e9Z �90 90 6T i�C
rroprRy a,w��a���� ..- •--•� - ----- ---
. .. _
� ...._......._...._..._......._._.,...,....._........._._.........._y.._................_,.....__......_......._............._.._.._...__.__.._._._........_...._..,..,..,.___._......._._._..._
� �vstem.Comnonent�(P/ease describe the s stem components and attach slte sketch showing system/ocadon):
- �► k
k
What methods were used to make the determinations for the�moifance in�(Note:No standard protoco/exlsts.
The follow/ng list is nut exhaustive, o�/n sequential order nor Jndicates whlch combinahons may necessary to make a determ/nation)
Watertight tank(s) Hydraullc Functioning Vertical Separetion Distance
� Probed tank bottom � Searched for sutface outlet � Conducted soll borings ,�
❑ Observed low liqu(d level O Performed hydraulic test Depth to limiting layer ��
❑ Examined const. records � Searched for seeping in yard Depth to system bottom
3g ''
� Examined empty(pumped)tank ❑ Checked for back-up in home ❑ Examined records
❑ Probed outslde tank for"black soil" ❑ Excessive ponding in soil system/D-boxes ❑ LGU Limfting Laye�Verlficatlon
o Pressure/vacuum check ❑ Homeowner testimony O Other
O Other � Examined for surging in tank
Cl "61ack soil"above soil system
��,L 'j'av►� — ��I o Other
st tus of the svstem _
eased on the compliance criteria,the system tus is: (check one)�failing (to protect groundwater) � an
imminent threat to public health or safety (ITPHS),�non-compliant(monito�ing issue) ❑ compliant(none of the 3
previous conditions). Therefore,this documenfi is a: ❑ Certificate of Compliance �Notice of Noncompiiance
Is this system an EPA Class V Injection Well? ❑ yes no
Certiflcation
I hereby certify as a state of Mlnnesota licensed Inspector and/or Designer I or Qualified Employee Inspeetor and/or QualfAed Empioyee
Designer I that I conducted an investigation that accurdtely determined the compliance status of this system and that my recorded
abservadons are accurate as of thls date. No determinatlon of future hydraulic pe�formance has heen nor can be made due to
unknown condtions during system constructlon, abuse of the system,inadequate maintenance,or future water usage.
Inspector's name (print) JOSH SWEDLUND Phone ^ 73' 3�
License and/or Registration Number 25�2 Address � r � `S ,
Employed by v �✓� 1C� C� Address �l�Je—
Signature
Date
de E 1 e jderlved from Minnesota Slatutes§�15.SSJ
An ITPHS must be upg2ded, rep/ace�d,or!ts use discontinued within ten manths of receipt af tf►!s notrce or w/t�hin a shorier pe�iod!f
required by/oca/ordinance, If the system fa1/s to pmv/de suf)`fcient groundwater protection, then the system must be upgraded,
rep/aced, or its use discondnued withrn the Cime requi�d by ru/e or fhe/oca/ordinance. If an eristing system/s not fai/inq as deFned in
law,and has at least 1wo feet of design soil sepa�ation, then the system need not be upgraded, repaJred,�ep/aced, or its use
discontinue�d, notwithstanding any Mca/ordinance that is more strict. This does not apply tb systems/n shore/and a�s, we//head
protectfon areas, or!`liose used in connection with food, beverage,and/odging estabUshments as defined in/aw.
SuaQested Attachr�ents
1) Site sketch could also include: well, well setback to system,dwelling or other buildings, tank(s),reserved soil treatment area,
surtdce water and soil boring locatlons. Inciude as-builk drawing if available.
2) Soil boring logs, showing each horizon. Indicate the texture, color, redoximorphic features depth to bedrock,standing water and �
whether the material is fill.
3) A list of any and all requirements of the local ordinance that are different from the state requirernents refeRed to on this form.
4) A homeowner survey of system performance, signed by the homeowner as being factual.
S) Monitoring data as appropriate.
� Page Z of 2
E 'd z6ZE-EL6 [ZS6l puntpamg yso� e9Z �90 90 6T t�C
CERTIFICATE OF INSPECTION
ACCORDING TO MPCA 7080
ORONO BUILDING & ZONING DEPARTMENT
2750 Kelley Parkway
P.O. Box 66
Crystal Bay, MN 55323
This certificate has been issued this 25t'' day of July 2011, to certify compliance with
provisions of the Orono Municipal Code and Minnesota Rules Chapter 7080, regulating
installation of individual sewage treatment systems.
Owner: Myron & Patricia Westfall Site Address: 4680 North Arm Drive W
P.I.D.: 06-117-23-32-0006 Permit #: 2007-11316
Installer: Jim's Excavating
Compliance Officer:
w �L.J�I�L/V
data/forms/blank cert of inspection MPCA 7080