975 Cliff Rd - Septic Compliance Inspection Form CI (05.10.17)Minnesota Pollution
Control Agency
Compliance Inspection Form
20 Lafayette Road North h Existing Subsurface Sewage Treatment Systems
5St. Paul, MN 55155-4194 (SSTS)
Doc Type: Compliance and Enforcement
Instructions: Inspection results based on Minnesota Pollution Control Agency (MPGA) For local tracking purposes:
requirements and attached forms — additional local requirements may also apply.
Submit completed form to Local Unit of Government (LUG) and system owner
within 15 days
System Status
System status on date (mm/dd/yyyy):
0 Compliant - Certificate of Compliance
(Valid for 3 years from report date, unless shorter time
frame outlined in Local Ordinance.)
Noncompliant - Notice of Nonco pliance
(See Upgrade Requirements on page 3)
Reason(s) for noncompliance (check al! applicable)
❑ Impact on Public Health (Compliance Component #1) — Imminent threat to public health and safety
❑ Other Compliance Conditions (Compliance Component #3) — Imminent threat to public health and safety
0 Tank Integrity (Compliance Component #2) — Failing to protect groundwater
❑ Other Compliance Conditions (Compliance Component #3) — Failing to protect groundwater
up Soil Separation (Compliance Component #4) — Failing to protect groundwater
❑ Operating permit/monitoring plan requirements (Compliance Component #5) — Noncompliant
Property Information Parcel ID# or Sec/Twp/Range: 10-02600-56-010
Property address: 975 Cliff Road Eagan Reason for inspection: Property Transfer
Property owner: Millicent Johnson Owner's phone: 651-238-6055
or
Owner's representative: Representative phone:
Local regulatory authority: Dakota County Regulatory authority phone: 651-675-5000
Brief system description:
Comments or recommendations:
Certification
I hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No
determination of future system performance has been nor can be made due to unknown conditions during system construction,
possible abuse of the system, inadequate maintenance, or future water usage.
Inspector name: Gary M. Bohn Certification number: 959
Business name: Bohn Well D
Inspector signature:
Necessary or Locally Required Attachments'
Soil boring logs
0 Other information (list):
System/As-built drawing
License number: 1043
Phone number: (952) 445-4809
0 Forms per local ordinance
www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats
wq-wwists4-31 • 1/24/12 Page 1 of 3
Property address: 975 CIiff Road Eagan
1. Impact on Public Health — Compliance component #1 of 5
Inspector initials/Date: _1(11
Compliance criteria:
System discharge sewage to the
ground surface.
System discharge sewage to drafri tile
or surface waters.
dwelling or establishment.
0Yao ENn
[]Yee No
System cause sewage backup intoEl Yes le No
Any "yes" answer above indicates the system is
an !mminent Threat to Pub!ic Health and Safety.
Comments/Explanation:
2. Tank Integrity — Compliance component #2 of 5
Verification method(s):
/#1 Searched for surface outlet
111 Searched for seeping in yard/ackup in home
El Excessive ponding in soil system/D-boxes
O Homeowner testimony (See CommontsxExplanauto)
O "Black soil" above soil dispersal system
O System requires "emergency" pumping
O Performed dye test
O Unable to verify (See CommentslExplanation)
O Other methods not Iisted (See Comments/Exp/anation)
Compliance criteria:
System consists of a seepage pit,
cesspool, drywell, or leaching pit.
Seepage pits meeting 7080.2550may be
compliant if allowed in local ordinance.
[]Yes ENo
Sewage tank(s) leak below their
designed operating depth.
0Yes 01 No
lfyes, which sewage tank(s) leaks:
Any "yes" answer above indicates the
system is Failing to Protect Groundwater.
�
—'___-_�
Verification method(s):
el Probed tank(s) bottom
LJ Examined construction records
LJ Examined Tank ntegrity Form (Attach)
LJ Observed hquid tevel below operating depth
O Examined empty (pumped) tanks(s)
[] Probed outside tank(s) for "black soil"
LJ Unable to verify (See Comments/Explanation)
O Other methods not listed (See Comments/Explanation)
3. Other Compliance Conditions — Compliance component #3 of 5
a. Maintenance hole covers are damaged, cracked, unsecured, or appear to structurally unsound.[]Yes El No []Unknown
b. Other issues (electrical hazards, etc.) to immediately and adversely impact public health or safety. []vas giwn 0 Unknown
*System is an imminent threat to public hea!th and safety
Explain:
c. System is non -protective of ground water for other conditions as determined by inspector
*System is failing to protect groundwater
0 Yes*
�
v*°w.pca.,tate.mn.u, ^ 651'2966300 • 800657'3864 • TTY 651-282 5332 or 800-657-3864 • Available inalternative fonnms
wq-wwists4-31 • 1/24/12
Page 2 of 3
Property address: 975 Cliff Road Ea an Inspector initials/Date: :Sol
A �I�
4. Soil Separation - Compliance component #4 of 5
Date of installation:
Shoreland/Wellhead protection/Food Beverage
Lodging?
Compliance criteria:
® Unknown
❑ Yes NI No
For systems built prior to April 1, 1996, and
not located in Shoreland or Wellhead
Protection Area or not serving a food,
beverage or lodging establishment:
Drainfield has at least a two -foot vertical
separation distance from periodically
saturated soil or bedrock.
❑ Yes No
Non-performance systems built April 1,
1996, or later or for non-performance
systems located in Shoreland or Wellhead
Protection Areas or serving a food,
beverage, or lodging establishment:
Drainfield has a three-foot vertical
separation distance from periodically
saturated soil or bedrock.*
❑ Yes ❑ No
"Experimental", "Other", or `Performance
systems built under pre -2008 Rules; Type IV
or V systems built under 2008 Rules (7080.
2350 or 7080.2400 (Advanced Inspector
License required)
Drainfield meets the designed vertical
separation distance from periodically
saturated soil or bedrock.
❑ Yes ❑ No
Any "no" answer above indicates the system is
Failing to Protect Groundwater.
Verification method(s):
Soil observation does not expire. Previous soil
observations by two independent parties are sufficient,
unless site conditions have been altered or local
requirements differ.
® Conducted soil observation(s) (Attach boring logs)
❑ Two previous verifications (Attach boring logs)
❑ Not applicable (Holding tank(s), no drainfield)
D Unable to verify (See Comments/Explanation)
❑ Other (See Comments/Explanation)
Comments/Explanation:
Indicate depths of elevations
A. Bottom of distribution media
B. Periodically saturated soil/bedrock
C. System separation
f ,
D. Required compliance separation*
*May be reduced up to 15 percent if allowed by Local
Ordinance.
5. Operating Permit and Nitrogen BMP* - Compliance component #5 of 5 E Not applicable
Is the system operated under an Operating Permit? 0 Yes ❑ No If "yes", A below is required
Is the system required to employ a Nitrogen BMP? 0 Yes 0 No If "yes", B below is required
BMP=Best Management Practice(s) specified in the system design
If the answer to both questions is "no", this section does not need to be completed.
Compliance criteria
a. Operating Permit number:
Have the Operating Permit requirements been met?
b. Is the required nitrogen BMP in place and properly functioning? 0 Yes 0 No
Any "no" answer indicates Noncompliance.
❑ Yes ❑ No
Upgrade Requirements (Minn. Stat. § 115.55) An imminent threat to public health and safety (iTPHS) must be upgraded, replaced, or its use
discontinued within ten months of receipt of this notice or within a shorter period if required by local ordinance. If the system is failing to protect
ground water, the system must be upgraded, replaced, or its use discontinued within the time required by local ordinance. If an existing system
is not failing as defined in law, and has at least two feet of design soil separation, then the system need not be upgraded, repaired, replaced, or
its use discontinued, notwithstanding any local ordinance that is more strict. This provision does not apply to systems in shoreland areas,
Wellhead Protection Areas, or those used in connection with food, beverage, and lodging establishments as defined in law.
www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats
wq-wwists4-31 • 1/24/12 Page 3 of 3
UNIVERSITY
OF MINNESOTA
Septic System Drawing
Property Owner/Client: Millicent Johnson
List any construction issues:
Mapping Checklist
Map scale:
Locate
0 Lot Dimensions/Property Lines
ri Dwellings and Other Improvements
_J Existing or Proposed System(s)
P1 Replacement Area
11 Unsuitable Area(s)
Public Water Supply Wells
[j Pumping Access
Li Inner Wellhead Zone
indicate north
show slope
% direction
Easements Setbacks
0 Phone 0 Building
0 Electric E All water wells within 100 feet
LJ Gas Ei Pressure Pipe
Elevations
L j Water Suction
Benchmark P1 Streams, Lakes
0 Borings P1 Floodway and Fringe
111 Perc Tests
P1 Horizontal and Vertical Reference Points
Elevations in feet
System Corners:
NW:
NE:
SW:
SE:
Soil Borings:
#1:
#2:
#3:
Tank Outlet:
Onsite Sewage Treatme
z
0
ea•
+.) 0
L)
.5
Loose-„,
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Finn
Extremely Firm
Rigid
g
''''
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g
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7)
0
34
Loose
Friable
Firm
Extremely Firm
Rigid
Loose
Friable
Firm
Extremely Firm
Rigid
Weak
-4,4oses 41
Strong
Loose
bp 0
Weak
Strong
Loose
Weak
Moderate
Strong
Loose
Weak
Moderate
Strong
Loose
Weak
Moderate
Strong
Loose
.grar..v)6
v)
Granular
Platy
14420
rismatic
Single Grain
Massive
Granular
Platy
Blocky
Prismatic
Single Grain
Massive
Granular
Platy
Blocky
Prismatic
Single Grain
Massive
A•
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ir-, al a.‘ in
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Concentrations
Depletions
Gleyed
Concentrations
Depletions
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Concentrations
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M. T® 12 n20/1
5325 MANNING AVE. SO., AFTON, MN 55001
Family Owned Business Since 1978
LANA MEYER
(651) 459-0162
Liquid Waste pumped Portable Toilet and Sink Rental
www.MeyerSewer.com
CHEC
CASH
C .ARGE
=1
CREDIT CARD CHARGES DATE
PLEASe CALL -�
417
Fy
PUMPED AND BACKFLUSHED.
Cesspool
Holding Tank
Lift. Station
Distnbutlon or Junction Box
Extra Backflushing
feet of hose (Extra charge for over 100 feet o
Washington, County Fee
PUMPED:
5andtrap
Sump.`
Other:`
Weaken or Evening Charge
RECEIVED BY
TOTAL GALLONS`
1500)
TOTAL -
aQvl
.5-
Pumped through or inspection pipe
Septic tank: - - �-ock- Plastic Unknown
.Overflow tan -recast .Block - Plastic -Unknown
Condition of baffle- ..o. Repair Needed, or Unknown
Dramfield Mound {k or: Unknown
Effluent surface dischae Yes -or i
Lift Station' Yes,or'�
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