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