904 Lakewood Hills Rd - Septic Maintenance Form 2022-06-09$MI N N SOTA POLLUTION Ei
CONTROL AGENCY Sewage tank
S.PauLafayette
MN
aad 5-4194North maintenance reporting form
St. Paul, MN 55155-4194
Subsurface Sewage
Treatment Systems (SETS) Program
Doc Type: Compliance and Enforcement
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, only a tank integrity assessment, 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. Page 3 is
optional and not required to be completed on routine maintenance events.
Secure maintenance hole covers
All maintenance hole covers must be retumed 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 atter 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 waming 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.
Reporting information
Date of maintenance (mm/ddtyyyy):
Reason for maintenance: h� �� P
Property address: ,,
City: _� 1 Parcet lD:
State: M n Zip coder j
,���
Property owne s name: -'�; _
Property -owner's address (if different):
City: State:
Phone number: Zip code:
Email address:
1. Did you measure the accumulation of scum and sludge? ® Yes ❑ Notank s
{ {)pumped without measuring)
Tank check if resent) Scum Slud e
Operating depth ticholdintank #1lPercent full
Septic/holding tank #2
❑ Pretreatment tank
2. Access used to remove septage: Maintenance hole ❑ Other (Unless a holding tank, go to #4 below)
3. If the maintenance hole was used, were all covers secured in place? Yes
❑ No if no, please explain below.
Actual Size- Tank#1 Tank #2
Tank #3/Pump Tank
l
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.
1' , 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.
By typing/signing my name below, I certify the above statements to be true and correct, to the best of my knowledge, and
that this information can be used for the purpose of processing this form.
Owner's signature:
Date (mm/dd/yyyy):
www.pca.state.mn.us 651-296-6300 • 800-657.3864 •
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Property address: 904 LXk�� 006 9 -CA
City: state: _(YN
5.
A -
Is the tank designed as a leaky tank? (Example: seepage pit, cesspool, drywell, leaching pit)
Tank #1: 0 Yes No Verification method used:
Tank #2: El Yes ONO Verification method used:
Parcel ID:
Zip code:
Is there evidence of the Tonowing-r
Maintenance hole cover is
Tank leaks below the
Tank leaks above the
damaged, cracked, unsecured, or
Tank (check if present)
designed operatin depth
designed operatinq depth
appears to be structy ly unsound
e tic/holding Tank #1
0Yes
rXN0
❑ Yes'-
W No
0 Yes ffNO
fielholding Tank #2
C1 Sep
C] Yes
0, No.
[I Yes
El No
Q Yes Q No
Ej Pretreatment Tank
El Yes
Q -No
El Yes
El No
0 Yes QNo
Pump Tank
El Yes
Q No
El Yes
Q No
Yes El No
Describe detail for any "Yes'
7. How many gallons of septage were removed?
Tank #1: j = Tank #2:
Pretreatment Tank:
Pump Tank:
8. Where was the septago taken? 0 Wastewater treatment facility 0 Land application 0 Other
Explanation (Facility name/Site #): Blue Lake
19. Did you identify any operational issues or unsafe conditions while assessing the sewage tanks in this system?
[)Yes 0 No If yes, identify tank and explain:
El Evidence of non-domestic waste [I Baffle(s) condition n Effluent screen condition
El Maintenance hole and extensions condition n 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:
I
=M
Additional comments or suggestions for owner's consideration:
7T"1MT7:=
owner:
I personally conducted the work described above on behalf of a Minnesota licensed SSTS Maintenance Business, in compliance
with Minnesota Rules Chapters 7080 — 7083:
ZAs 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.
By typing1signing my name below, I certify the above statements to be true and correct, to the best of my knowledge, and that
this information can be used for the purpose of processing this form.
Company information
Company name: Mikes Septic &,McKinley Sewer
Business license number: L 1665 & L2899
Email:
Employee's signature:
www.pca.state.mn.us
wqwww&0-38 * 4128121
Employee information
Print name: L/
Certification number: (if applicable):
Phone number: 952-440-1800
Date (mm/dd/yyyy):
651-2W6300 4 $00-657-3864 Use your preferred relay service
Available In alternative formats
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