3319 Roll Lane - Code Compliance - Septic Tank Abandonment Inspection ReportINSPECTRON, INC.
CODE COMPLIANCE INSPECTIONS
15120 Chippendale Ave., Suite 202 Rosemount, MN 55068
Phone 651-322-6626 • Fax 651-322-7580 • Toll Free 1-800-322-6153
INSPECTION REPORT
PROJECT TITLE
PROJECT LOCATION/ADDRESS
OWNER ,
PERMIT NO.
RECEIVED
AUG 1 4 1020
JURISDICTION
SCHEDULED FOR: DAY 11; DATE t;
0 RE-INSP./FOLLOW-UP
0 FOOTINGS
0 POURED WALL
0 FOUNDATION
0 SITE UTILITY
O FIREPLACE ROUGH -IN
0 PLUMBING ROUGH -IN
O MECHANICAL ROUGH -IN
0 FRAMING
CONTRACTOR
0 INSULATION
0 FIRE RATED WALL BOARD
0 FIRE ALARM SYSTEM
0 FIRE SUPPRESSION R.I.
0 FIRESTOPPING
0 FIRE/SMOKE DAMPER
0 FIRE CODE INSPECTION
0 ISTS STANDARD
-DIMS OTHERSYSTKM
TIME
0 PLUMBING FINAL.
0 MECHANICAL FINAL
O FIREPLACE FINAL
O GAS. PRESSURE TEST
0.FIRE SUPPRESSION FINAL
O BUILDING FINAL
d PROGRESS
OCOMPLAIMT
•
O WORK IS SATISFACTORY. OK TO PROCEED
O CORRECT WORK, THEN OK TO PROCEED
O CORRECT WORK. CALL FOR REINSPECT BEFORE COVERING.
O STOP WORK IMMEDIATELY! CALL INSPECTOR.
0 INSPECTION REQUIRED. CALL AND ARRANGE FOR ACCESS.
DATE INSPECTED: TIME ARRIVED ON SITE: TIME INSP.COMYLE=D:
TOTAL INSPECTION TIME: INSPECTOR SIGNATURE:
Date of abandonment:
Minnesota Pollution
Control Agency
520 Lafayette Road North
St. Paul, MN 55155-4194
RECEIVED
AUG 14 2020
SSTS Abandonment
Reporting Fora
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
Lig3 I
Reason for abandonment: .............6:1.1
_...__....___....
Property owner name(s):°
Property owners address:
City: - - .._ 11�.._,-._........ —
Site address (if erent):
City:
Compliance Information
1. All solids and liquids removed from all tanks?
Disposal Site:
•
k
Yes ❑ No
State: ' "—...._..-._. Zip: J
State:
2. All electrical devices and devices containing mercury removed?
Disposal Site:
Yes ❑ No
3. All underground sewage tanks crushed and filled with soil or rock material? Yes ❑ No or
Removed and disposed off site? ❑ Yes ❑ No
Disposal Site:
Zip:
4. Contaminated materials* removed and disposed off site? Ces ❑ No �. .�}- �. err .-1 d
Disposal Site:
5. All underground cavities** crushed and filled with soil or rock material? es ❑ No or:
Removed and disposed off site? ❑ Yes ❑ No
Disposal Site:
6. Future discharge to system permanently denied?
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 • Available in alternative formats
wq-wwists4.03 • 11/21/08 Page 1 of 2
• RECEIVED
Map AUG 141010
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.
North
Certification
1 hereby certify the system was abandoned in accordance with Minn. R. 7080.2500 and any local requirements.
Name (please print):
Address:
City:
Phone:
Date:
5"1-
tc-W'
Signature:
Title
State:
Li.cerrse # if applicable)- i 4
Zip:f
www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • ITY 651-282.5332 or 800-657-3864 • Available in alternative formats
wq-wwists4-03 • 11/21/08 Page 2 of