3120 Pilot Knob Rd - SSTS Abandonment Reporting Form
Minnesota Pollution
Control Agency SSTS Abandonment
524 Lafayette Road North Reporting Form
St. Paul, MN 55155-41%
Subsurface Sewage Treatment Systems (SSTS) Program)
Instructions
This form is offered to meet the abandonment requirements of Minn. R. 7080.2500 and Disclosure Requirements of Minn. Stat.
§ 115.55, subd. 6. Future water supply well placement can also be affected by an abandoned SSTS.
The use of this form is not mandatory; however the information on this form must be submitted to the local government unit (LGU)
within 90 days after the abandonment. This form may be completed by a certified SSTS practitioner or by an individual who has
direct knowledge of how the system was abandoned.
Property Information
Date of abandonment: 9 6 2012 Reason for abandonment: hooked to city sewer
Property owner name(s): Clare (burg
Property owner's address: 4393 upper 135th. st. w
City: Rosemount State: Mn. Zip: 55068
Site address (if different): 3120 Pitt Knob Road
City: Eagan State: Mn. Zip: 550123
Compliance Information
1. All solids and liquids removed from all tanks? ® Yes El No
Disposal Site:
2. All electrical devices and devices containing mercury removed? El Yes ® No
Disposal Site: none gravity type
system.
3. All underground sewage tanks crushed and filled with soil or rock material? ® Yes ❑ No or
Removed and disposed off site? El Yes ® No
Disposal Site:
4. Contaminated materials* removed and disposed off site? El Yes n No
Disposal Site:
5. All underground cavities** crushed and filled with soil or rock material? ® Yes n No or:
Removed and disposed off site? n Yes El No
Disposal Site:
6. Future discharge to system permanently denied? ® Yes n No
Method(s) used: pipe cut and hooked to city sewer
*Contaminated materials = Distribution media, soil or sand within three feet of the system bottom, distribution pipes, geotextile
fobric/rosin paper/straw, tanks, contaminated soil around leaking tanks, any soil that received sewage
from a surface failure (7080.2500 subp.3).
"*Underground cavities = Cesspools, leaching pits, drywells, seepage pits, vault privies, pit privies, pump chambers
(7080.2500 subp. 1). Does not include chamber media, drop boxes, or distribution boxes.
www.pca.state.mn.us 651-296-6300 • 800-657-3864 TTY 651-282-5332 or 800-657-3864 • Available in alternative formats
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Map
Include location of building sewer, septic tank(s), soil dispersal system, cesspools, seepage pits, and other pits. Also
include a permanent reference point(s) and dimensions.
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Certification
I hereby certify the system was abandoned in accordance with Minn. R. 7080.2500 and any local requirements.
Name (please print): Jerry Sauber Title: President Sauber P&H CO.
Address: 100 P. st.
City: Farmington St . Mn.. Zip: 55024
Phone: 651 463 7434 Licens if ap cable): 317 & 925
Date: 9 6 2012 Signature:
www.pca.state.mn.us • 651-296-6300 800-657-3864 TTY 651-282-5332 or 800-657-3864 Available in alternative formats
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