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1350 Rocky Lane - Sewage System As-Built INDIVIDUAL SWAGE SYSTEM AS-BUILT Date 1 stalledo Permit Nor ,of / Ob Owner: r v► Project Address , : use Type: III Property ID No.(PIN) - _ _ _ _ _ _ _ (Dak Co Tax Info 651-438-4576, or www.co.dakota.mn.us) 6tY Installed for-3 Bdrms or ~ s _ al/day ommercial Use? Y / N W~ ❑New eplace ❑Repair ❑Addition (v Property Transfer Upgrade? Y 49 Bsmt Lift P mp? YY Future? Jacuzzi? 1 /~f Garb`~jis{~ Soil Survey Map Unit Oa9, Soil Compacted?Y /a Fill Soil? Y /0 $ if Circle Soil Texture: (Faster than 0.1 mpi) j Coarse Sand I ✓ Medium Sand Loamy Sand 0.83 FINES 1 ND 1.67 andy Loam 1. o 1.67 Silt Loam, Silt 2.00 Sandy Clay Loam 2.2 Silty Clay Loam Clay Loam 1 1114 Silty Clay, Clay 4.2 f 146 (Slower than 120 mpi) Soil dry enou for 1 construction N SETBACKS: Prop.Lines 10'1_ Bldgs 10' to Tank & 20' to Drnfid V _ Well(s) setbac ( )not installed et 7 i Well Depth ( )Orig. Well Record ( )Measured Distance to Lake_Creek AeA Wetland Buried Water Pressure Lines 10' to Tank & Drnfld? Line drawn from Tanks to Pump Truck Access < 100'y?& N System located by Photos? 'Y GPS? Y /V RESERVE AREA? (5/ N Fenced Off? Y16 SEPTIC / HOLDING TANK(S) Y]New ❑ Existing Owner informed to preserve Reserve Area? / N Liquid Capaci compartment o Owner given Septic System Owner Guide? Y /O Made by G` ~s Watertight? dP/ N TRENCHES / BED R GRAVELLESS DRAINFIELD- Baffle Type: asflc Fiberglass Sanitary-T Concrete Drop boxes level? Type cone t / astic No. of Inspection Ipes 1''4" / 6" d' m. ank vel? / N Trench Depth Width No./Diam. Manhole Access` nie / u ent Number of Trenches Trench Bottom Level / N No. & Height of Manhole Risers - g New Tanks 4 ft or less below Final Grade / N Trench Lengths-~ Spacing Pipes into Tank Sealed? with 00 Rock Clean?YEN 2' over Pipe? YIN GeoTextile Qo_v%?Y/N N Depth Below Pipe? " Soil Backfill Depth " Riser into Tank Base Sealed? with 4 /N Gravelless Pipe Si ? Made by Outlet Effluent Filter? Y Type Chamber Size? Made b _ ND / ATGRADE: Absorption Area: Sq Ft Lineal F1 60 Perce lope Scarification Method: rench Bottom to mottling / bedrock?+ inches Dike Width Up Down Side p ANK Made by Ca ac' Clean Rock? Y Depth Below Pip inches No. & Hel f Risers Se p ac J N Clean Sand? Y / N D Upslop Downsiope Pump Manufact M # Inches to Mottling Pipe Spacing Horsepower GP F of Head Perf Size/Spacing- Fin over Depth Cycles Per Day Gallo er Cycle Rock Bed Size Supplier: Size of Discharge Line Jr.5" j 2°' Sand Base Supplier: Type of Electrical H up pos ox by.tank Upslop eding drainage/diversion? Y / N Pro d? Y/ N Alarm Locatio garage J ba nt Gr ' g done: Rough / Final Alarm: T lert / Level Alarm / Other )Seeding ( )Sod to be done by: C c ounter? YIN Water Meter? YIN I hereby certify, as installer, that this individual sewage treatment system Designated Registered was installed according to the ap roved design, and as applicable, this Professional Onsite c Municipality's e go Tre t Syst Or finance, & accurately locates all system co n is f r reloc PCA Lic. No. UL Company Name t/ s / Gz Ins r ~ Si Date: Ph6 Address ` Sign ~ Date:e/0/3gpproved: No/~es Ye wi h ono White copy: Count y Yellow:Owner Pink:lnstaller o:\e m g m t\forms\wa l m\i sts\as-built-f o rm. d oc MINNESOTA PRECAST INDUSTRIES, INC. 5480 142 nd STREET EAST ROSEMOUNT, MN. 55068 OFFICE # (651) 437-2200 TANK IDENTIFICATION DOCUMENT (INSTALLER MUST SUBMIT THIS DOCUMENT WITH AS B DRAWING) JOB ADDRESS.-/350 k0c 1 L/)lj~ 100q 10 ALL TANKS ARE ENGINEERED & MANUFACTURED TO WITHSTAND 84.00 INCHES OF RISER-SOIL ABOVE TANK LID. (CIRCLE ONE) 1ST TANK: MODEL: 1000 SEPTIC 1250 PUMP 150 HOLDI 1000/500 (L-c-o-'mp--l' 500S/1000P REVERSE LIQUID CAPACITY IN GALLONS1000 1250 1500 1000/50 50011000 DATE TANK WAS MANUFACTURED: --Y 2O y (CIRCLE ONE) 2ND TANK: MODEL: 1000 SE IC 1250 PUMP 1500 HOLDING 1000 00 2-COMP. OOS/1000P REVERSE LIQUID CAPACITY IN GALLO 1000 1250 1500 1000/500 50011000 DATE TANK WAS MANUFAC UR -20 (CIRCLE ONE) 3RD TANK: MODEL: 1000 EPTIC 250 PUMP 1500 HOLDING 1000/500 2-COMP. 500S/1000 REVERSE LIQUID CAPACI IN GALLONS1000 1250 150 1000/500 500/1000 DATE TANK W MANUFACTURED: -20 .10 Minnesota Pollution SSTS Abandonment Control Agency 520 Lafayette Road North Reporting Form 5t. Paul, MN 55155-41% Subsurface Sewage Treatment Systems (SETS) 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: Reason for abandonment: !a C- Property owner name(s): ~l'► Property owner's address: Lon - City:k-v State: Zip: Site address (if diffe rnt). City: State: Zip: 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? AYes ❑ No Disposal Site: 3. All underground sewage tanks crushed and filled with soil or rock material? YYes ❑ No or Removed and disposed off site? ❑ Yes ❑ No Disposal Site: 4. Contaminated materials' removed and disposed off site? ❑ Yes ❑ No Disposal Site: &10 5. All underground cavities" crushed and filled with soil or rock material? Yes ❑ No or: Removed and disposed off site? ❑ Yes ❑ No Disposal Site: 6. Future discharge to system permanently denied? Yes ❑ No Method(s) used: "Contaminated materials Distribution media, soil or sand within three feet of the system bottom, distribution pipes, geotextile fabric/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 • Availabte in alternative formats wq-wwists4-03 • 11121108 Page 1 of 2 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. T North 0 ~1d~r V Certification I hereby certify the syste47~#qi? bandoned in accordance with Minn. R. 7080.2500 and any local requirements. Name (please print): Altj Ai46 Title: z1/ Address: 173 City: rAhif 001 State: Zip: 55 -4-V.2 Phone: - License i plica Date:- Signature: www.pca.state.mn.us • 651-296-6300 800-657-3864 TTY 651-282-5332 or 800-657-3864 Available in alternative formats wq-wwists4-03 • 11121106 Page 2 of 2