781 Hackmore Dr - Septic Compliance Inspection - Noncompliant 2018-09-10Minnesota Pollution
Control Agency
520 Lafayette Road North
St Paul, MN 55155-4194
CompHance hspection Form
Existing Subsuiftce ftwage Treatment Systems 13STS)
For local tracking purposes:
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System status on date (mmiddlyyyy): -A�
F-1 Compliant - Certificate of Compliance a,Noncompliant - Notice of Noncomplian
(Valid for 3 years from report date, unless shorter time (See Upgrade Requirements on page 3.)
frame outlined in Local Ordinance.) I
Reason(s) for noncompliance (check all applicable)
M Impact on Public Health (Compliance Component #1) — Imminent threat to public health and safety
El Other Compliance Conditions (Compliance Component #3) — Imminent threat to public health and safety
0 Tank Integrity (Compliance Component #2) — Failing to protect groundwater
M Other Compliance Conditions (Compliance Component #3) — Failing to protect groundwater
[R'Soil Separation (Compliance Component #4) — Failing to protect groundwater
[] Operating permiUmonitoring plan requirements (Compliance Component #5) — Noncompliant
INIMPrelaXAMi SUM-Mition Parcel ID# or Se uTw /Ran *
' L
Property addr AQ A5!
Property owner:
tr
Owner's representative:
Local regulatory authority:
Brief system description:
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-, - - I - I I -
Regulatory authority phone:i5�7X--S—ao o
Comments or recommendations:el"54("m7
I hereby cerW 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: Certification number: 12
Business name: el. License number:
Inspector signature' '�7 010'000Phone number. :x AKS-- 2, /3 Y"
Arsoil boring logs F1 System/As-built draiWing
0 Other information
\NV1rW.pca.state.mn.us . 651-296-6300 - 800-657-3864 TTY 651-282-5332 or 800-657-3864 - Available in alternative formats
wq-wwists4-37b - 614114 Page 7 of 3
Property address:Inspector inifials[Date' :?uv F
(mmlddlyyyy)
System discharges sewage to the i 0 Yes (No
System discharges sewage to drain ❑ Yes CR No
tile or surface waters.
System causes sewage backup into ❑ Yes RNo
dwelling or establishment.
Any "yes"answer above indicates the
System is an ffmminent threat to public
hea kh and safety.
System consists of a seepage pit,
cesspool, drywell, or leaching pit.
Seepage pits meeting 7080.2550 may be
mmoliant if allowed in local ordinance.
Sewage tank(s) leak below their
designed operating depth.
ifYes, which sewage tank(s) leaks:
Verification method(s):
W searched for surface outlet
Searched for seeping in yard/backup in home
Excessive ponding in soil system/D-boxes
Homeowner testimony (See CommentslExplanation)
■"Black soil" above soil dispersal system
F1 System requires "emergency" pumping
■ Performed dye test
■Unable to verify (see CommentsExplanation)
Verification method(s):
n Yes [31' No aProbed tank(s) bottom
n Examined construction records
n Examined Tank Integrity Form (Attach)
El Observed liquid level below operating depth
El Yes No E] Examined empty (pumped) tanks(s)
Any "yes" answer above indicates the
system is failing to protect groundwater.
CommentsiEnplanation:
0 Probed outside tank(s) for "black soil"
F-1 Unable to verify (See Comments/Explanation)
F1 Other methods not listed (See Comments/Explanation)
® Other Compliance Conditions — Compliance component #3 of 5
a. Maintenance hole covers are damaged, cracked, unsecured, or appear to be structurally unsound. 0 Yes* No El Unknown
b. Other issues (electrical hazards, etc.) to immediately and adversely impact public health or safety. []Yes* No n Unknown
*system is an imminent threat to public health and safety.
Explain:
c. System is non -protective of groundwater for other conditions as determined by inspector. [BYes*
*System is failing to protect groundwater.
Explain:
\N\AFW.PCa.state-rnn.us . 651-296-6300 m 800-657-3864 TTY 651-282-5332 or 800-657-3864 - Available in attemative formats
..Wq-wwiSt54-31b - 614114 Page 2 of 3
Property address: Inspector initials/Date:
(Mmlddlyyyy)
I — Compliance component *4 of 5
Date of installation: Zo El Unknown Verification method(s):
(mmlddlyyyy)
ShorelandMellhead protection/Food beverage F, yes M7NO Soil observation does not expire. Previous soil
lodging? observations by two independent parties are sufficient,
unless site conditions have been altered or local
Compliance criteria: requirements differ.
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
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.*
17 Yes No 07conducted soil observation(s) (Attach boring logs)
F1 Two previous verifications (Attach boring logs)
0 Not applicable (Holding tank(s), no drainfield)
El Unable to verify (See Comments/Explanation)
El Other (See Comments/Explanation)
E]Yes R No Comments/Explanation:
"Experimental", 'Other", or "Performance" 0 Yes 0 No
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.
'[flay be reduced up to 15 percent if allowed by Local
Ordinance.
5. 02erating Permit and Nitrogen BMP* — Compliance component #5 of 5 . [2 -Not applicable
Is the system operated under an Operating Permit? 0 Yes M No If "yes", A below is required
Is the system required to employ a Nitrogen BMP? F1 Yes n No If "yes", B below is required
BMP = Best Management Pracfice(s) specified in the system design
If the answer to both questions is ,no-, this section does not need to be Completed.
IIEN-47CM
b. Is the required nitrogen BMP in place and prop�t UI functioning? 171 Yes No
Any "no "answer indicatL-S Noncompliance.
Upgrade Requirements (Winn. Stat § 115.55) e-
. 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 Shorterperiod 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 upgradea repaired, replaced, or
its use discontinued, notwithstanding any local ordinance that is more sinct. This provision does not apply to systems in shlend areas,
Wellhead Protection Areasore
, or these used in connection with food, beverage, and lodging establishments as defined in law.
www-pca.state.mn.us - 651-296-6300 - 800-657-3864 •rPi- Available in atternative formats
wq-ww1sts4-31b - 614114
Page 3 of 3
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