3120 Pilot Knob Rd - Septic Compliance Form 2012-07-13System Status
Minnesota Pollution
Control Agency �,��
520 Lafayette Road Norte.
St. Paul, MN 55155 -4194
System status on date (mm /dd /yyyy): 7—(3- 2 at L.
❑ Compliant - Certificate of Compliance
(Valid for 3 years from report date, unless shorter time
frame outlined in Local Ordinance.)
■
Inspector name:
r
Business name:
signature:
Co pUUance inspection Form
Existing Subsurface Sewage Treatment Systems
(SSTS)
Doc Type: Compliance and Enforcement
Instructions: Inspection results based on Minnesota Pollution Control Agency (MPCA)
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
Local regulatory authority: Gd 171 54n 1
Brief system description: 3- o r d 04., fa bikiwikuss TA-At--5
Comments or recommendations:
AK* weQr j ava t it ere6 'f/4 4 -`',
For local tracking purposes:
'Noncompliant - Notice of Noncompliance
(See Upgrade Requirements on page 3)
Reason(s) for noncompliance (check all applicable)
❑ Impact on Public Health (Compliance Component #1) - Imminent threat to public health and safety
0 Other Compliance Conditions (Compliance Component #3) - Imminent threat to public health and safety
ank 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 /' )narcel ID# or Sec/1 /Range:
Property address: °` o v1 d Xe ■ , o. /44 Reason for inspection:, _,w4.o;'f"
Property owner: ,4s4c`p �' +1,40 Owner's phone: , / .,2„o P
or //''
Owner's representative: t Representative phone: t
Regulatory authority phone: 4, / - 4.+7S s o
Certification
1 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.
Certification number:
License number:
Phone number:
3�' 7
IC
Necessary or Locally Required Attachments
❑ Soil boring logs 0 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 • Available in alternative formats
wq- wwists4.31 • 1/24/12 Page 1 of 3
Property address: /2.0 4767 t . „� r�r Inspector initials /Dat
• Impact on Public Health — Compliance component #1 of 5
a.
b.
Com • stance criteria:
System discharge sewage to the ❑ Yes YNo
round surface.
System discharge sewage to drain tile ❑ Yes} "No
or surface waters.
System cause 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:
. Tank integrity — Compliance component #2 of 5
Compliance criteria:
System consists of a seepage pit,
cesspool, drywell, or leaching pit.
Seepage pits meeting 7080.2550 may be
compliant if allowed in local ordinance.
Sewage tank(s) leak below their
designed operating depth.
If yes, which sewage tank(s) leaks:
X ❑ No
❑ Yes W' No
Any "yes" answer above indicates the
system is Failing to Protect Groundwater.
Comments /Explanation:
3. Other Compliance Conditions — Compliance component #3 of 5
Verification method(s):
Searched for surface outlet
'[P Searched for seeping in yard /backup in home
❑ Excessive ponding in soil system /D -boxes
❑ Homeowner testimony (See Comments /Explanation)
❑ "Black soil" above soil dispersal system
❑ System requires "emergency" pumping
❑ Performed dye test
❑ Unable to verify (See Comments/Explanation)
❑ Other methods not listed (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 Comments/Explanation)
❑ Other methods not listed (See Comments/Explanation)
Maintenance hole covers are damaged, cracked, unsecured, or appear to structurally unsound. ❑ yes* ur No ❑ Unknown
Other issues (electrical hazards, etc.) to immediately and adversely impact public health or safety. ❑ Yes* V 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
*System is failing to protect groundwater
Explain:
❑ Yes* pkNo
www.pca.state.mn.us n 651-296-6300 a 800-657-3864 a TTY 651 -282 -5332 or 800-657-3864 . Available in alternative formats
wq- wwists4 -31 . 1/24/12 Page 2 of 3
Property address: 320 -tom/ Qb es, L Q
4. Soil Separation — Compliance component #4 of 5
Date of installation: 1 G , ►1 Unknown
Shoreland/wellhead protedionlFood Bevera
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 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.*
"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.
0 Yes
❑ Yes
❑ No
Any "no" answer above indicates the system is
121
❑ Yes ❑ No
❑ Yes ❑ No
a. Operating Permit number:
Have the Operating Permit requirements been met?
b. Is the required nitrogen BMP in place and properly functioning?
Any "no" answer indicates Noncompliance.
Inspector initials /Date:
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)
❑ 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
A. Required compliance separation*
Failing to Protect Groundwater. *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
❑ Yes ❑ No if "yes ", A below is required
❑ Yes ❑ No If "yes ", B below Is required
is the system operated under an Operating Permit?
Is the system required to employ a Nitrogen BMP?
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
❑ Yes ❑ No
❑ Yes ❑ No
/5
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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 ' 17Y 651-282-5332 or 800- 657 -3864 Available in alternative formats
wq- wwists4-31 . 1/24/12
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