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4385 S Robert Tr - Septic Compliance Form 2023-09-11MINNESOTA POLLUTION CONTROL AGENCY Compliance inspection report form 520 Lafayette Road North Existing Subsurface Sewage Treatment System (SSTS) 5t. Raul, MN 55155-4194 Doc Type: Compliance and Enforcement Instructions: Inspector must submit completed form to Local Governmental Unit (LGU) and system owner within 15 days of final determination of compliance or noncompliance. Instructions for filling out this form are located on the Minnesota Pollution Control Agency (MPCA) website at hitps:/lw m.pca.state.rnn.us/sites/default/fiileslwtlwwists4-31a.pdf. Property information Local tracking number: Parcel ID# or Sec/Twp/Range: Reason for Inspection Transfer Local regulatory authority info: Dakota County(City Of Eagan) Property address: 4385 S. Robert Trail Owner/representative: Jeff Black Owner's phone: 651-246-9704 Brief system description: 150012 Compartment Septic, 1000 Pump Chamber, Gravity Trench Drainfieid. System status System status on date (mmidd/yyyy): 9/11/2023 ® Compliant — Certificate of compliance* (Valid for 3 years from reportdate unless evidence of an imminent threat to public health or safety requiring removal and abatement under section 145A. 04, subdivision 8 is discovered or a shorter time frame exists in Local Ordinance.) 'Note: Compliance indicates conformance with Minn. R. 7080.1500 as of system status date above and does not guarantee future performance. ❑ Noncompliant— Notice of noncompliance Systems failing to protect ground water must be upgraded, replaced, or use discontinued within the time required by local ordinance. An imminent threat to public health and safety (ITPNS) 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 or under section 145A. 04 subdivision 8. Reason(s) for noncompliance (check all applicable) ❑ Impact on public health (Compliance component #1) — Imminent threat to public health and safety ❑ Tank integrity (Compliance component #2) — Failing to protect groundwater ❑ Other Compliance Conditions (Compliance component #3) — Imminent threat to public health and safety ❑ Other Compliance Conditions (Compliance component #3) -- Failing to protect groundwater ❑ System not abandoned according to Minn. R. 7080.2500 (Compliance component #3) -- Failing to protect groundwater ❑ Soil separation (Compliance component #5) — Failing to protect groundwater ❑ Operating permit/monitoring plan requirements (Compliance component #4) -- Noncompliant - local ordinance applies 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. By typing 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. Business name: Mike's Septic and Mckinley Sewer Certification number: 8067 Inspector signature: Matt Mckinley License number: 2899 (This document has been electronically signed) Phone: 952-440-1800 Necessary or locally required supporting documentation (must be attached) ® Soil observation logs ® System/As-Built ® Locally required forms ® Tank Integrity Assessment ❑ Operating Permit ❑ Other information (list): https://www.pca.state.mn.us 651-296-6300 • 800-657-3864 Use your preferred relay service • Available in alternative formats w_q-wwists4-31b • 4/28/2021 Page 1 of 4 Property Address: 4385 S. Robert Trail Business Name: Mike's and Mckinlev Sewer 1. Impact on public health — Compliance component #1 of 5 Date: 9111/2023 Compliance criteria: Attached supporting documentation: 3 System discharges sewage to the ❑ Yes" ® No ❑ Other: ground surface ❑ Not applicable System discharges sewage to drain ❑ Yes' ® No the 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. Describe verification methods and results: Visual. 2. Tank integrity— Compliance component #2 of 5 Compliance criteria: System consists of a seepage pit, 1, ❑ Yes* ®No cesspool, drywell, leaching pit, or other pit? 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. Describe verification methods and results: Empty tanks with camera. Attached supporting documentation: ® Empty tank(s) viewed by inspector Mike's Septic Name of maintenance business: and Mckinley License number of maintenance business: 2899 Date of maintenance: 9/11/2023 ❑ Existing tank integrity assessment (Attach) Date of maintenance (mm/dd/yyyy): (must be within three years) (See fora instructions to ensure assessment complies with Minn. R. 7082.0700 subp. 4 B (1)j ❑ Tank Is Noncompliant (pumping not necessary -explain below) ❑ Other: https://www.pca.state.mn.us 651-296-6300 800-657-3864 Use your preferred relay service Available in alternative formats wq-wwists4-31b • 4/28/2021 Page 2 of 4 Property Address: 4385 S. Robert Trail Business Name: Mike's Septic and Mckinlev Sewer Date: 9/11/2023 3. Other compliance conditions— Compliance component #3 of 5 3a. Maintenance hole covers appear to be structurally unsound (damaged, cracked, etc.), or unsecured? ❑ Yes' ® No ❑ Unknown 3b. Other issues (electrical hazards, etc.) to immediately and adversely impact public health or safety? ❑ Yes" ® No ❑ Unknown *Yes to 3a or 3b - System is an imminent threat to public health and safety. 3c. System is non -protective of ground water for other conditions as determined by inspector? ❑ Yes* ® No 3d. System not abandoned in accordance with Minn. R. 7080.2500? ❑ Yes' ® No *Yes to 3c or 3d - System is failing to protect groundwater. Describe verification methods and results: Attached supporting documentation: ❑ Not applicable ❑ 4. Operating permit and nitrogen BMP* — Compliance component #4 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 BMP specified in the system design? ❑ Yes ❑ No If "yes", B below is required BMP = Best Management Prectice(s) specifier) in the system design If the answer to both questions is "no". this section does not need to be completed. Compliance criteria: a. Have the operating permit requirements been met? ❑ Yes ❑ No b. Is the required nitrogen BMP in place and properly functioning? ❑ Yes ❑ No Any "no" answer indicates noncompliance. Describe verification methods and results: Attached supporting documentation: ❑ Operating permit (Attach) ❑ https://www.pca.state.mn.us 651-296-6300 • 800-657-3864 • use your preferred relay service • Available in alternative formats wq-wwists4-31b • 4/28/2021 Page 3 of 4 Property Address: Business Name: Mike's Septic and Mckinley Sewer Trail S. Soil separation — Compliance component #5 of 5 Date of installation 3/30/2016 ❑ Unknown (mm/dd/yyyy) Shoreland/Wel Ihead protection/Food ❑ Yes ® No beverage lodging? Compliance criteria select one): 5a. For systems built prior to April 1, 1996, and ❑ Yes ❑ No* 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. 5b. 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." Date: 9/11/2023 Attached supporting documentation: ® Soil observation logs completed for the report ❑ Two previous verifications of required vertical separation ❑ Not applicable (No soil treatment area) ® Yes ❑ No* Indicate depths or elevations 5c. Experimental", "Other", or Performance" ❑ Yes ❑ No* systems built under pre -2008 Rules,- Type ules;Type IV or V systems built under 2008 Rules 7080. 2350 or 7080.2400 (Intermediate Inspector License required 5 2,500 gallons per day; Advanced Inspector License required n 2,500 gallons per day) Drainfield meets the designed vertical separation distance from periodically saturated soil or bedrock. *Any "no" answer above indicates the system is failing to protect groundwater. Describe verification methods and results: 3" Bucket Auger, Munsell Color Guide. A. Bottom of distribution media_ 1 29" B. Periodically saturated soil/bedrock I Not found to 65" H D. Reauired co 36" 36" "May be reduced up to 15 percent if allowed by Local Ordinance, 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. https://www.pca.state.mn.us 652-296-6300 800-657-3864 Use your preferred relay service Available in alternative formats wq-wwists4-31b • 4/28/2021 Page 4 of 4 L 0 LO 00 M q�t ■ z L E u A I 1 a 1 c -.a y8' w-rr u. G FL tat .a U. w CA LL tt I _.t tz lz w m V- tL a O W ix eu1 D�� 'G- ee ♦R ? t% 410 ix Lol LOVXjla U as uyS2 ru a in RIVE I a a ;" a ¢tarn X Ln g 4 to \ V In } 4.0 � , J � W CL U�L� t3�U" O 1�G1�!7 ca3�U' U©l7 C� t � 1A3 ffi O �Iltl F ed clu v J E u A 1 a CW °gypp' 8..xs-..H c -.a y8' w-rr u. G FL tat .a U. w CA LL tt I _.t tz lz w m V- tL a O W ix eu1 D�� 'G- ? t% ix k U as uyS2 ru a in RIVE I a a ;" a ¢tarn Ln to N U In 4.0 � , J � CL U�L� t3�U" V C�l'3 1�G1�!7 ca3�U' U©l7 C� O J O MMINNESOTA POLLUTION CONTROL AGENCY 520 Lafayette Road North St. Paul, MN 55155-4194 Sewage tank maintenance reporting form Subsurface Sewage Treatment Systems (SSTS) 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 sewagetanl: 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 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. Reporting information Date of maintenance (mmldd/yyyy): 9/1112023 Reason for maintenance: Compliance inspection Property address: 4385 S. Robert TH. Parcel ID: City: Eagan State: MN. Zip code: 55123 Property owner's name: Jeff Black Property -owner's address (if different): City: State: Zip code: Phone number: 651-246-9704 Email address: jblack4l89@gmaii.com 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 ® Se ticlholdin tank #1 0" 12" ❑ Septic/holding tank #2 ❑ Pretreatment tank ® Pump tank _ _ _ _ 0" 2" 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: 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. I, , refuse to allow the removal of the solids and liquids through the maintenance (Print )wner'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 typinglsigning 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: www.pca.state.mn.us wq-wwists4-38 - 4/28/21 Date (mm/ddlyyyy)-. • 651-296-6300 - 800-657-3864 Use your preferred relay service Available in alternative formats Page 1 of 3 Property address: City: Eagan 4385 S. Robert Tri. State: M N. Parcel ID: Zip code: 5. Is the tank designed as a leaky tank? (Example: seepage pit, cesspool, drywell, leaching pit) Tank #1: ❑ Yes ® No Verification method used: Camera Tank #2: ❑ Yes ® No Verification method used: Camera B. Is there evidence of the following? 55123 Tank check if resent Tank leaks below the designed operating depth Tank leaks above the designed operatina de th Maintenance hole cover is damaged, cracked, unsecured, or appears to be structurally unsound ® Septic/holding Tank #1 ❑ Yes ®No i ❑ Yes ® No ❑ Yes ® No ❑ Septic/holding Tank #2 ❑ Yes ❑ 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: 1500 Tank #2: 8. 9. Pretreatment Tank: Pump Tank: 400 Where was the septage taken? ® Wastewater treatment facility ❑ Land application ❑ Other Explanation (Facility name/Site #): Blue Lake Treatment Did you identify any operational issues or unsafe conditions while assessing the sewage tanks in this system? ❑ Yes ® No If yes, identify tank and explain: ❑ Evidence of non-domestic waste ❑ Baffie(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: ❑ Troubleshooting and repairs conducted: I ❑ Repairs declined by owner: Additional comments or suggestions for owner's consideration: Pumping record 1 personally conducted the worts 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. 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. Company information Company name: Mike's Septic and Mckinley Sewer Business license number: 2899 Email: mckinleysewer@gmail.com Employee's signature: Matt Mckinley Employee information Print name: Matt Mckinley Certification number: (if applicable): 8067 Phone number: 952-440-1800 Date (mmlddiyyyy): 9/11/2023 www.pca.state.mn.us 651-296-6300 800-657-3864 Use your preferred relay service Available in alternative formats wq-ww15ts4-38 • 4/18/11 Page 2 of 3 Property address: City: Eagan 4385 S. Robert Trl. State: MN. Parcel ID: Zip code: 55123 Optional section: Sewage Tank Compliance Certification (Tank integrity assessment) This form does not represent a complete system inspection report and only certifies sewage tank compliance status. i.e., this form, completed, may serve as a tank integrity assessment. Instructions: This section of the form may be completed and signed by a Designated Certified Individual (DCI) of a licensed SSTS Maintenance Business who personally conducts the necessary procedures to assess the compliance status of each sewage tank in the system. When this section of the form is signed by a qualified certified professional, it becomes necessary supporting documentation to an Existing System Compliance Inspection Report: Compliance inspection form - Existing system (wcl-wwists4-31 b). This form can be found on the MPCA website at httpsa/www.pca.state.mn.us/waterlservice-and-maintenance. The information and certified statement on this form is required when existing septic tank compliance status is determined by an individual other than the SSTS Inspector that submits an inspection report. This form represents a third party assessment of SSTS component compliance and is allowable under Minn. R. 7082.0700, subp. 4 Item (B) subitem (1). This form is valid for a period of three years beyond the signature date on this form unless a new evaluation is requested by the owner or owner's agent or is required according to local regulations. Additional Administrative Rule references for this activity can be found at Minn. R. 7082.0700, subp. 4 Items B, C, and D; 7083.0730 item C. Pages 1 and 2 are not required to accompany this form when the optional third page is completed and used to certify sewage tank compliance status. System status System status on date (mm/dd/yyyy): 9111!2023 ® Certificate of sewage tank compliance ❑ Notice of sewage tank non-compliance Compliance criteria: The SSTS has a seepage pit, cesspool, drywell, leaching pit, or other pit - "Failure to Protect ❑Yes* ® No Groundwater." The SSTS has a sewage tank that leaks below the designed operating depth - "Failure to Protect ❑ Yes* ® No Groundwater." The SSTS presents a threat to public safety by reason of structurally unsound (damaged, cracked, or El Yes* ® No weak) maintenance hole cover(s) or lids or any other unsafe condition - "Imminent Threat to Public Health or Safety." Any "yes" answer above indicates sewage tank non-compliance. Company information Company name: Mike's Septic and Mckinley Sewer Business license number: 2899 Designated Certified Individual (DCI) information Print name: Matt Mckinley Certification number: 8067 1 personally conducted the work described above as a Designated Certified Individual of a Minnesota -licensed SSTS Maintenance Business. t personally conducted the necessary procedures to assess the compliance status of each sewage tank in this SSTS. 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. Designated Certified Individual's signature: Matt Mckin Date (mm/dd/yyyy): 9/11/2023 www.pca.state.mn.us 651-296-6300 800-657-3864 • Use your preferred relay service • Available in alternative formats wq-wwists4-38 • 4128121 Page 3 of 3