1390 Rocky Lane - Septic Compliance Inspection 2017-07-22 k L
Minnesota Pollution 1111 ? A�I/ Co 'ance mp ' � Form
Control Agency
520 Lafayette Road North b Gam° � ��� �lr Zys�gmz X35 7 6)
St.Paul,MN 55155-4194 Doc Type:Compliance and Enforcement
Inspection results based on Minnesota Pollution Control Agency(MPCA) 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(mm/dd/yyyy):
CeUtfflcate of' CornpHance ❑ WOncOmPflant-- Notice of Mancomp8lance
(Valid for 3 years from report date, unless shorter time (See Upgrade Requirements on page 3.)
frame outlined in Local Ordinance.)
Reason(s)for noncompliance (check all applicable)
❑ Impact on Public Health(Compliance Component#9)-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 ginformat»on Parcel ID#or Sec/Twp/Range:
Property address: 2— p:9
Reason for inspection:
Property owner. C Owner's phone: �--- o �2, 10
or —
Owner's representative: { l Representative phone: t i
Local regulatory authority: r —. / Regulatory authority phone: , /_ G - y-yo C;
Brief system description)� ma c, ., G✓! :C&/l u
Comments or recommendations:
CertfflCat�on
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 maint ance, or future water usage. I
Inspector name: i- �-,�,� �,.�- j--
Certification number:
Business name: _ - License number:
Inspector signature Phone number: ,e-'S /- KC 3 �7y 3
Necessary or Locaf ly Required Attachments
❑Soil boring logs System/As-built drawing ❑Forms per local ordinance
❑Other information(list):
www.pca.state.mn.us o 651-296-6300 0 800-657-3864 0 TTY 651-282-5332 or 800-657-3864 s Available in alternative formats
wq-wivists4-31b - 614114
Page Iof3
Property address:
Inspector initials/Date: ?u%
(mmlddlyyyy)
1. Impact on Public Health—Compliance component#1 of 5
_Compliance criteria: Verification method(s):
System discharges sewage to the ❑Yes U No 1�1 Searched for surface outlet
ground surface. ('Searched for seeping g in y ardlbacku
pin home
System discharges sewage to drain j ❑Yes No
�" ❑Excessive ponding in soil systemiD-boxes
tile or surface waters.
!! -- &-Homeowner testimony(See Comments/Explanation)
System causes sewage backup into I ❑Yes &�-No ❑"Black soil"above soil dispersal system
dwelling or establishment.
--- ❑System requires"emergency"pumping
Any"yes"answer above indicates the ❑Performed dye test
SYStGm is an imminent threat to public
i'lec�i�i`a'and S�?fZ'�� ❑ Unable to verify(See CommentslExplanation)
❑Other methods not listed (See CommentslExplanation)
Comments/Explanation:
20 Tack 8nteglrity—Compliance component#2 of 5
Compliance criteria: `verification method(s):
System consists of a seepage pit, I ❑Yes XNo ❑Probed tank(s)bottom
cesspool,drywell,or leaching pit.
�9'Examined construction records
Seepage pits meeting 7080.2550 may be
_compliant if allowed in local ordinance. j ❑ Examined Tank integrity Form (Attach)
Sewage tank(s)leak below their ❑Yes VNo ❑Observed liquid level below operating depth ,
designed operating depth. ( Examined empty(pumped)tanks(s) -��olv��t`�
If yes,which sewage tank(s)leaks. I ❑Probed outside tank(s)for"black soil" L-1 r� �
Any "yes"answer above indicates the ❑Unable to verify(See CommentslExplanation)
SYSteM is fa in y' ttO PrOteCt grQ3UnII water. ❑Other methods not listed (See CommentslExplanation)
Comments/Explanation:
3. Other Compijance Conditions—Compliance component#3 of 5
a. Maintenance hole covers are damaged,cracked,unsecured,or appear to be structurally unsound. ❑Yes* JX*No ❑Unknown
b. Other issues(electrical hazards,etc.)to immediately and adversely impact public health or safety. ❑Yes* R 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 wiling to protect groundwater. ,
Explain:
i
I
- 1
www.pca.state.mn.us o 651-296-6300 800-657-3864 TTY 651-282-5332 or 800-657-3864 Available in attemative formats
wq-wwists4-31b o 614114
Page 2 of 3
Property address: /
�G -� inspector initials/Date —Z2— /
(mmlddiyYYY)
4. Soil Separation—Compliance component#4 of 5
Date of installation: (117
_ [I Unknown Verification method(s):
(mmlddlyyyy)
Shorelandlwellhead protection/Food beverage Soil observation does not expire.Previous soil
lodging? ❑Yes �o
observations by two independent parties are sufficient,
Compliance criteria; unless site conditions have been altered or local
requirements differ.
For systems built prior to April 1, 1996,and i
not located in Shoreland or Wellhead ❑Yes El No l,�Conducted soil observations) ]fi
Protection Area or not serving a food,
❑Two previous verifications(Attach boring logs)
beverage or lodging establishment:
❑Not applicable(Holding tank(s),no draintield)
Drainfield has at least atwo-foot vertical
separation distance from periodically ❑Unable to verify(See Comments/Explanation)
saturated soil or bedrock. + ❑Other(See CommentslExplanation)
Non-performance systems built April 1 yes
1996, or later or for non performance 7'� El No Comments/Explanation:S
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 ❑Yes El No Indicate depths or elevations
or V systems built under 2008 Rules(7080.
2350 or 7080.2400 (Advanced Inspector A Bottom of distribution media
License required) --
t
B. Periodical) saturated soil/bedrock r�Z
Drainfield meets the designed vertical
separation distance from periodically C. System separation
saturated soil or bedrock.
_ D. Required compliance separation* 3 /
Any "no"answer above indicates the sysfeil7�is *May be reduced up to 15 ercent if
failing to Protect groundwater. Ordinance. p allowed by Local
50 Operating PerMit and Nitrogen BMP*—Compliance component
Is the system operated under an Operating Permit? N #5 ��� Not applicable
❑Yes ❑No If"yes",A below is required
Is the system required to employ a Nitrogen BMP?
❑Yes ❑No if"yes",B below is required
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
a. Operating Permit number:
Have the Operating Permit requirements been met? ❑Yes ❑No
b. Is the required nitro en BMP in place and propedy functioning?
Any"no"answer indicates N®ncOMpliiance. LEI Yes ❑No
Upgrade Requirements(Minn.Stat.§115.55)An imminent threat to public health and safety(ITPHS must be
discontinued within ten months of receipt of this notice or within a shorter period if required by local ordinance.If the
ground water,the system must be u ) upgraded,replaced,or its use
upgraded,replaced,or its use discontinued within the time required by local oMinanceenf an exl is�ng 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
its use discontinued,notwithstanding any local ordinance that is more strict. This provision does not apply to s stems in
Wellhead Protection Areas,or those used in connection with Toad,beverage,and lodging establishments as defy g ed,repaired,replaced or
Y shoreland areas,
red in law.
www.pCa.state.mn.us - 651-296-6300
800-657-3864 o TTY Y 651-282-5332 or 800-657-3864
6/4/14 Available in alternative formats
Page 3 of 3
ON-SITE SEWAGE TREATMENT SYSTEM - rNSpECT16N REPORT
/Y Date of inspection:
Applicant and Pcrrrut#:
PP Parcel ID:
Inspected by:
C '��t 'c� �•c_ �t r�
• Site Address: ��lQ•__ �!_���'�'
Municipality[rownship: --�
WS . :':::';1.1,;•1
1.�:.-..-.'.:•:.:.\.. ..::.-.-: L ,..�•.-
J \
#Soil Borings `5_Depth to Restriction House Type: I II III
(Inches)
#Perc Test _ Garbage Disposal: Yes/No
-_— •r)�pe hiottl'__ S�lroeit V4'ai.a table
#of Bedrooms
Average Perc Rate Acceptance Rate
n (sq.WsA #Potential Bedrooms
Reserve Area' es 00 _
.:::::.;:......... .:: ...•-:.: P:TiC.TA�`'K��PE:C�t.C�TiO�S
....::.::.:..
Number of Septic Tanks �4 Outlet a rain- 3"below inlet
, _ Inspection Pipes(4"mim)
- Capacity(i,000&lviin) Horizontal Dimension(2a~ ) Manhole(24"min.)
Fre fab Tank Mod el:(�esY No Tank is:cvel
l Pumping tank Yes&o)
Outlet Bale(35%of total liquid
Inlet Baffle 6~below liquid-1°
depth-6"above liquid surfa:cc) abov'sc inid crown) Capacity
Liquid Depth(30"min.) Watertight Construction
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perty ( ) (10')
Recreation&Tributary(7s')
ell(7s•)
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(1so')
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�L Property Lines(1o')
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�i Watertight Construction Pipe to Drop Box(unpetforaled) Box is Level
Inlet Inverts(l"above outlet `7 Outlet Inverts(a~above floor) Distribution: r is ityJ Pressure
invert)
Pipe Connection
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r Size of Washed Rock(3/4"to
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inches Bottom of Trench to Water
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N SCALE:
feet
Site Drawing;
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Designer. L -- --- V
- 4 �' Approved: Yes[No
Installer: `,e J�-<�- /;Z-/'/'-z -1
Signature: