1025 Wescott Rd - SSTS Abandonment Form 2016-10-12 Minnesota Pollution SSTS Abandonment
Control Agency
520 Lafayette Road North Reporting Form
St,Paul,Mfg 55155-41
Subsurface Sewage Treatment Systems ( 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
Bate of abandonment: = Reason for abandonment:
Property owner name(s): Wael Sakallah
Property owner's address: 2920 Talmage Ave
City: Minneapolis Stater M Zip: 55413
-.. --- --
Site address(if different): -- - -- -
- - --
City: — --------- - ----- State: Zap: - _ Z, _..__-
Compliance Ifr ti
1. All solids and liquids removed from all tanks? Yes Flo
Disposal Site: -
2 All electrical devices and devices containing mercury removed? El Yes El No
Disposal Site:
3. All underground sewage tanks crushed and filled with soil or rock material? R Yes El No or
Removed and disposed off site? E]Yes No
Disposal Site: _
4. Contaminated materials' removed and disposed off site? El Yes N No
Disposal Site:
5, All underground cavities-crushed and filled with soil or rock material? 0 Yes E] No or:
Removed and disposed off site? Yes E] No
Disposal Site:
6. Future discharge to system permanently denied? Ed Yes El No
Method(s) used:
"Contaminated materials= Distribution media, soil or sand within three feet of the system bottom, distribution pipes, geotextile
fabricl rosin paperlstraw, tanks, contaminated soil around leaking tanks, any soil that received sewage
from a surface failure(7080.2500 subp.3).
-Underground cavities= Cesspools, teaching pits, drywells, seepage pits, vault privies,pit privies,pump chambers
(7080.2500 subp. 1). noes not include chamber media, drop boxes, or distribution boxes.
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pca.state.mn.us 651-296-6300 800-657-3864 s TTY 651-282-5332 or 800-657-3864 • Available in alternative formats
wq ists4-03 a 11121108 Page'1 of 2
Map
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.
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Certification
I hereby certify the system was abandoned in accordance with Minn. R. 7000.2500 and any local requirements.
Name(please print): Bohn Well Drilling Go Gerry Bohn — Title: Owner
Address: 13190 DairLane Suite 101.- —..------ —-- -- ----------- ------- --— —------- -
City: Jordan---- -------- --------------- State: M-N Zip: 55352
---------. ..---------..---------
Phone: 952-445=4309-- ----- —--—--- License if applicable): 1445
Date. �`��� — __— —---- ----------
a �W Signature: .
www.pca.state.mn.us 551-296-6300 800-657-3864 TTY 651-282-5332 or 800-657-3864 ® Avaitable in alternative formats
wq ists4-03 ® 11121108 Page 2 of 2
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All claims and returned goods IMU ST be accompanied by this bi1I. � _ �_