704 Nauvoo Lane - Septic Abandonment FormsA-5 tt Niinniota Pollution SSTS Aba
Contr;I Agency
sa0 LafarN55,
oad North
Repos
St. Patti,155-4194
Subsurface Sewage TreatMont Systems
Instructions
This form is offered 110 meet the abandonment requirements of Minn. R. 7484.2500 and Disclosure Requires
§ 115.55, subd. 6. ture water supply well placement can also be affected by an abandoned SSTS.
l
The use of this form its not mandatory-, however the information on this form must be submitted to the local l
within 90 days afteHthe abandonment This form may be completed by a certified SSTS practitioner or by a
direct knowledge oflow the system was abandoned.
Property Infor1maFr
Date of aband nmetit: 1 t Reason for abandonment:
6 41- w L'S ) 6
Property owner nan*(s): ky\eL r c- G.5 D �-
Property owner's ass: 7 NQ 14 V O D 4 re
City:ty R —
lt n State: � r
Site address (if diffo ent):-
City. State:
Compliance Irftrmation
1. All solids and liquids removed from all tanks? No
Disposal Site: r n k I S 4 -1 -OL -e �✓ �F Orn
les! - tj Y 9 - Sr _ Sr-
2. All electrical deices and devices
Disposal Site:
mercury removed? ❑ Yes ❑ No
3. All underground sewage tanks crush and filled with soil or rock material? ❑ Yes 11 No or
Removed and Disposed off ? tJ Yes ❑ No �} Qj
t o.0 ��otise. 21V !'�5e1"�
Disposal Site: -
4. Contaminated Oatedals`
Disposal Site:
fL'
and disposed off site? ❑ Yes aft
5. All underground# cavities" crushed and filled with soil or rock material? ( ❑ No or.
Removed and 4$sposed off site? ❑ Yes ❑ No
Disposal Site:
6. Future discharge to system penently denied?
Method(s) used: p e +^ UyA
❑ No
donment
,i ng Form
,STS) Program)
of Minn. Stat
unit (LGU)
who has
,_ New
ip: _S-/ 3L
ip:
V1 YJ
'Contaminated matoiats = Distribution media, soil or sand within three feet of the system bottom, dfstributi pipes, geotextile
fabric/rosin paper/straw, tanks, contaminated soil around leaking tanks, any soil t at received sewage
from a surface failure r70B0.2500 subp.3). l
'Underground covitles = Cesspools, teaching pits, drywells, seepage pits, vault privies, pit privies, pump chtr►bers
(7080.2500 subp. 1). Does not include chamber media, drop boxes, or distribution axes.
www.pca.state.mn.us: - 651-296-6300 • 800-657-3854 TTY 651-282-5332 or 800-657-3864 • Ava ble in altemative formats
wq-wwists4-03 • 11/11108 tar 1 of 2
Map
Include location of buildings wer, septic tank(s), soil dispersal system, cesspools, seepage pits,
include a permar#nt referenceoint(s) and dimensions.
T North
Certification
I hereby certify the-, pystem was abandoned in acgL)rd rice with Minn. R. 7080.2500 andanylocal req
Name (please printf: V-) 0. 0- y-- Title: _ V, 1l L 5
Address:I 3 S ( LQr Ne IVL,
City: n.2 In State: f7.
Phone: s % � o� 3 � - l D � f cense # if iica ):
Date: 'a j 3 signature:
� 2a Oj K
wvnv.pca.state.mn.us • 651-296-6300 • 800-657-3864 TTY651-282-5332or800-657-3864
wq-wwists4-03 • 1 I M 1 /08
other pits. Also
s
In attemative formats
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