861 Lakewood Hills Rd - Septic Compliance Inspection 2020-11-20Control Ag Pollution Compliance Inspection Form
Control Agency
520 Lafayette Road North Existing Subsurface Sewage Treatment Systems (SSTS)
St. Paul, MN 55155-4194 Doc Type: Compliance and Enforcement
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 (mmlddlyyyy): 11/20/2020
® Compliant — Certificate of Compliance
(Valid for 3 years from report date, unless shorter time
frame outlined in Local Ordinance.)
Reason(s) for noncompliance (check all applicable)
❑ Noncompliant — Notice of Noncompliance
(See Upgrade Requirements on page 3.)
❑ 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
❑ Tank Integrity (Compliance Component #2) — Failing to protect groundwater
❑ Other Compliance Conditions (Compliance Component #3) — Failing to protect groundwater
❑ Soil Separation (Compliance Component #4) — Failing to protect groundwater
❑ Operating permit/monitoring plan requirements (Compliance Component #5) — Noncompliant
Property Information Parcel 11]# or SecfFwp/Range:
Property address: 861 Lakewood Hills Rd. S. Reason for inspection: Buyer Request
Property owner:
or
Owner's phone:
Owner's representative: BUYER DennyHanson Representative phone: 612-741-0512
Local regulatory authority: City Of Eagan Regulatory authority phone: 651-675-5671 Sarah
Brief system description: 1500 Gal. Septic, Gravity Trenches
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: Matt Mcki
Business name: Mike's Septic + Mckinle Se er Services
Inspector signature:
Necessary or Locally Requi d A deachments
Certification number: 8067
License number: 2899
Phone number: 952-440-1800
® Soil boring logs ® System/As-built drawing ® Forms per local ordinance
❑ Other information (list):
www.pca.state.mn.us • 651-296-6300 800-657-3864 TTY 651.282-5332 or 800-657-3864 • Available in alternative formats
wq-wwists4-31b • 614114 Page 1 of 3
Properly address: 861 Lakewood Hills Rd. S. Inspector initials/Date: M.M. 1 11/20/2020
(mmlddlyyyy)
1. Impact on Public Health -- Compliance component #1 of 5
Compliance criteria:
System discharges sewage to the ❑ Yes ® No
ground surface.
System discharges sewage to drain ❑ Yes ® No
tile or surface waters.
System causes sewage backup into ❑ Yes ❑ No
dwelling or establishment.
Any "yes" answer above indicates the
system is an imminent threat to public
health and safety.
Comments/Explanation:
2. Tank Integrity — Compliance component #2 of 5
Compliance criteria:
System consists of a seepage pit, [:]Yes ® No
cesspool, drywell, or leaching pit.
Seepage pits meeting 7060.2550 may be
compliant if allowed in local ordinance.
Sewage tank(s) leak below their [:]Yes ® No
designed operating depth.
If yes, which sewage tank(s) leaks:
Any "yes" answer above indicates the
system is failing to protect groundwater.
Comments/Explanation:
Tanks pumped at time of compliance inspection.
Verification method(s):
® 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
❑ System requires "emergency" pumping
❑ Performed dye test
❑ Unable to verify (See CommenWExplanation)
❑ Other methods not fisted (See Comments/Explanation)
Verification method(s):
❑ Probed tank(s) bottom
® Examined construction records
❑ Examined Tank Integrity Form (attach)
❑ Observed liquid level below operating depth
® Examined empty (pumped) tanks(s)
❑ Probed outside tank(s) for "black soil'
❑ Unable to verify (See CommentslExplanation)
❑ Other methods not listed (See CommentslExplanation)
3. Other Compliance Conditions — Compliance component #3 of 5
a. Maintenance hole covers are damaged, cracked, unsecured, or appear to be structurally unsound. ❑ Yes* ® No ❑ Unknown
b. Other issues (electrical hazards, etc.) to immediately and adversely impact public health or safety. ❑ Yes* ® No ❑ Unknown
*System is an imminent threat to public health and safety.
Explain:
c. System is non -protective of ground water for other conditions as determined by inspector. ❑ Yes* ® No
*System is failing to protect groundwater.
Explain:
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Property address: 861 Lakewood Hills Rd. S. Inspector initialsiDate: M.M. 1 11%2012020
(mm/dd,y5W)
4. Soil Separation — Compliance component #4 of 5
Date of installation: 8/28/1990 ❑ Unknown
(mm/dd/yyyy)
5horelandlWellhead protection/Food beverage ❑ Yes ® No
lodging?
Compliance criteria:
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.
Non performance systems built April 1,
1996, or later or for nonperformance
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.*
"Experimental", "Other'; or Performance"
systems built under pre -2008 Rules; Type /V
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
❑ Yes ❑ No
❑ 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 drainfreld)
❑ Unable to verify (see Comments/Explanation)
❑ Other (See Comments, -Explanation)
Com ments/Explanation:
Indicate depths or elevations
A.
Bottom of distribution media
25 inches
B.
Periodically saturated soil/bedrock
not found to 65
inches
C.
System separation
40 inches
D.
Required compliance separation*
24 inches
*May be reduced up to 15 percent if allowed by Local
Ordinance.
5. Operating Permit and Nitrogen BMP* — Compliance component #5 of 5 ® Not applicable
Is the system operated under an Operating Permit? ❑ Yes ❑ No If "yes", A below is required
Is the system required to employ a Nitrogen BM P? ❑ Yes ❑ No If "yes", B below is required
BMP = Best Management Practices) 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?
BMP in of
Any "no" answer indicates Noncompliance,
❑ Yes ❑ No
0
Upgrade Requirements (Minn. Stat. § 115.55) An imminent threat to public health and safety (ITPHS) must be upgraded, replaced, orits use
discontinued within ten months of receipt of this notice or within a shorter period if required by focal 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 • Availabie in alternative formats
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MINNESOTA POLLUTION
CONTROL AGENCY
520 Lafayette Road North
5t. Paul, MN 55155-4194
Sewage tank
maintenance reporting form
Subsurface Sewage
Treatment Systems (SSTS) Program
Purpose: Management and maintenance of Subsurface Sewage Treatment Systems (SSTS) are important to ensure resource
protection and long-term and cost-effective sewage treatment. Completion of this form complies with the sewage tank maintenance
requirements under Minn. R. 7080.2450 and 7082.0600. This form may be used to certify the compliance status of the sewage tank
components of the SSTS. This form is not a complete SSTS inspection report and may only certify sewage tank compliance
status when entirely completed and signed on page 3 by a qualified professional.
Instructions: A copy of this information must be submitted to the system owner within 30 days of the maintenance date and be maintained
by the licensed SSTS maintainer business for a period of five (5) years from the maintenance date. Maintenance reporting to the local unit of
government may be required by local ordinance. Check with your local SSTS program for maintenance reporting protocol.
Secure maintenance hole covers
All maintenance hole covers must be returned to service in a sound and durable condition and be capable of withstanding
the anticipated load.
Covers must be re -secured in accordance with Minn. R. 7080.2450, subp. 3, Items C or D:
a) Covers installed under local ordinances adopted after February 4, 2008 must be locked, bolted or screwed or must be 95
pounds in weight. They must be made of material suitable for outdoor use, resistant to ultraviolet degradation and leaks, and
not susceptible to being slid or flipped. They must have a label warning of hazardous conditions inside the tank. All screw
openings must be refastened.
b) Covers installed under local ordinances adopted before February 4, 2008 must either be buried with at least 12 inches of
soil cover or be secured according to the local ordinance in effect before February 4, 2008.
c) Covers must meet item 'a' above when raised to the ground surface or less than 12 inches from the ground surface.
I
Reporting information
Date of maintenance (mmlddlyyyy): 111-2P-2-0 ) Reason for maintenance: lf,22! ,a 4,ICi-01
Property address: Parcel ID:
City:a cc /� Stater.-� Zip code: 6, -4�"3
Property owner s name:
Property -owner's address ifdifferen_
City: State: Zip code:
Phone number_ /„ ( `� — Q Si 2-- Email address:
1. Did you measure the accumulation of scum and sludge? ❑ Yes ❑ No (tank(s) pumped without measuring)
Tank (check if present) Scum Sludge Operating depth Percent full
ZSeptic/holding tank #1 o f`
❑ Se ticlholdin tank #2
F-1 Pretreatment tank
2. Access used to remove septage: 9Maintenance hole ❑ Other (Unless a holding tank, go to 94 below)
3. If the maintenance hole was used, were all covers secured in place? ( yes ❑ No If no, please explain below:
ACTUAL SIZE OF TANKS—TANK#1:ML - TANK#2: PUMP TANK
4. If the owner refuses to allow a Subsurface Sewage Treatment System (SSTS) to be pumped through the maintenance
hole, have them complete and sign the following statement.
, refuse to allow the removal of the solids and liquids through the maintenance
(Print owner's name)
hole. I understand that removal of solids and liquids through other access points is not considered a compliant method of
solids removal and does not fulfill the solids removal requirements of Minn. R. 7080.2450 and 7082.0600.
Owner's signature:
www.pca.state.mmus •
wq-wwists4-38 • 10/12/18
Date (mm/dd/yyyy):
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Page 1 of 3
Property address: �p ( �. ��e _ i i ��5
• 5-
Parcel Mi
City:
State: Ylf _! .
Zip code:
5. Is the tank designed as a leaky tank? (Example: seepage pit, cesspool, drywell, leaching pit)
Tank #1: ❑ Yes 0 No Verification method used:
p (�� ,�} '�1,a�c�
4
Tank #2: ❑ Yes ❑ No Verification method used:
6. is there evidence of the following?
Maintenance hole cover is
Tank leaks below the
Tank leaks above the
damaged, cracked, unsecured, or
Tank (check if present) desiqneg_qperating de th
designed operating depth
appears to be structurals unsound
Se ticlholdn Tank #1 ❑ Yes L4 No
ElYes MNo
ElYes gNo
❑ Septic/holding Tank #2 ❑ Yes Ll No
❑Yes No
❑ Yes ❑ No
❑ Pretreatment Tank []Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Pump Tank ❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
Describe detail for any "Yes'
7. How many gallons of septage were removed?
Tank #1: Tank #2: Pretreatment Tank: Pump Tank:
8. Where was the septage taken? ® Wastewater treatment facility ❑ Land application ❑ Other
Explanation (Facility name/Site #): 6_
9. Did you identify any operational issues or unsafe conditions while assessing the sewage tanks in this system?
❑ Yes X No If yes, identify tank and explain:
❑ Evidence of non-domestic waste ❑ Baffle(s) condition ❑ Effluent screen condition
❑ Maintenance hole and extensions condition ❑ Other conditions (e -g- structural integrity of tank or lid, electrical hazard, etc.)
Explanation:
10. List any troubleshooting and minor repairs completed or declined by owner:
❑ Troubleshootin and repairs conducted: ❑ Repairs declined b owner:
Additional comments or suggestions for owner's consideration:
Pumping record
I personally conducted the work described above on behalf of a Minnesota -licensed SSTS Maintenance Business, in compliance
with Minnesota Rules Chapters 7080— 7083:
® As a noncertified individual who has received proper training, daily work review, and periodic observation, or
❑ As a designated certified individual of the business listed below -
Company information Employee information
Company name: Mike's
Business license number: #1665
Email:
Employee's signature:
www.pca.state.mn.us • 651-296-6390 •
wq-wwists4-38 • 10/12/18
Print name:
Certification number: (ir applicable): NIA
Phone number: 952-440-1800
Date (mmidd/yyyy): 11--2e')_,20
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