750 Hackmore Dr - Septic Compliance Form 2023-12-01 NoncompliantCONTROL A ENCY POLLUTION Compliance inspection report form
CONTROL AGENCY p
520 Lafayette Road North Existing Subsurface Sewage Treatment System (SSTS)
St. Paul, 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 hops://www.pca.state mn us/sites/default/files/wg-wwists4 31a pdf.
Property information Local tracking number:
Parcel ID# or Sec/Twp/Range: Reason for Inspection Transfer
Local regulatory authority info: City of Eagan (Dakota Count )
Property address: 750 Hackmore Dr.
Owner/representative: Julie Yakovlove Owner's phone: 651-206-8076
Brief system description: 1000 gal. stave tank, 1000 gal. cessspool, gravity trench drainfield.
System status
System status on date (mm/dd/yyyy): 12/1/2023
❑ Compliant — Certificate of compliance*
(Valid for 3 years from report date 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.)
® 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 (ITPHS) must be
* upgraded, replaced, or its use discontinued within ten months of receipt
Note; Compliance indicates conformance with Minn, of this notice or within a shorter period if required by local ordinance or
R. 7080.1500 as of system status date above and does not under section 145A.04 subdivision 8.
guarantee future performance.
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
Stave tanks and cesspools are deemed automatic fail by minnesota state septic rules.
Certification
i nereby 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 Mcki
(This document has been electronically signed)
License number: 2899
Phone: 952-440-1800
Necessary or locally required supporting documentation (mast be attached)
IN Soil observation logs Z System/As-Built ® Locally required forms ® Tank Integrity Assessment ❑ Operating Permit
❑ Other information (list):
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Property Address: 750 Hackmore Dr.
Business Name: Mike's Septic and McN
Sewer
1. Impact on public health — Compliance component #1 of 5
Hance criteria:
System discharges sewage to the I ❑ Yes* ® No
ground surface
System discharges sewage to drain ❑ Yes" ® No
tile 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 safe
Describe verification methods and results:
Date: 12/1 /2023
Attached supporting documentation:
❑ Other:
❑ Not applicable
2. Tank integrity — Compliance component #2 of 5
Compliance criteria:
System consists of a seepage pit,
cesspool, drywell, leaching pit,
or other pit?
Sewage tank(s) leak below their
designed operating depth?
® Yes* ❑ No
® Yes* ❑ No
If yes, which sewage tank(s) leaks:
Any "yes" answer above indicates the system
is failing to protect groundwater.
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: 12/1/2023
❑ Existing tank integrity assessment (Attach)
Date of maintenance
(mm/dd/yyyy): (must be within three years)
(See form instructions to ensure assessment complies with
Minn. R. 7082.0700 subp. 4 8 (1))
❑ Tank is Noncompliant (pumping not necessary - explain below)
❑ Other:
Describe verification methods and results:
Dug open stave septic tank, pumped and camera used. As well drove pipe into dirt bottom on both tanks.
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Property Address: 750 Hackmore Dr.
Business Name: Mike's Septic and Mckinley Sewer Date: 12/1/2023
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 or3b - System is an imminent threat to public heaith and safety.
3c. System is non -protective of ground water for other conditions as determined by inspector?
3d. System not abandoned in accordance with Minn. R. 7080.2500?
"`Yes to 3c or 3d - System is failing to protect groundwater.
Describe verification methods and results:
Attached supporting documentation: ❑ Not applicable ❑
❑ Yes. ® No
❑ Yes` ® No
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 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. Have the operating permit requirements been met? ❑ Yes ❑ No
b. Is the required nitrogen BMP in place and properly functioning? ❑ Yes ❑ No
Describe verification methods and results:
Attached supporting documentation: ❑ Operating permit (Attach) ❑
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Property Address: 750 Hackmore Dr.
Business Name: Mike's Septic and Mckii
5. Soil separation — Compliance component #5 of 5
Date of installation 1/1/1972 ❑ Unknown
(mm/ddly3w)
Shoreland/Wellhead 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, orlodging establishment-
Drainfield has a three-foot vertical
separation distance from periodically
saturated soil or bedrock.*
Date: 12/1 /2023
Attached supporting documentation:
® Soil observation logs completed for the report
❑ Two previous verifications of required vertical separation
El 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 IV or V systems built under 2008
Rules 7080. 2350 or 7080.2400
(Intermediate Inspector License required <
2,500 gallons per day, Advanced Inspector
License required > 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:
Soil probe and munsell color guide.
A. Bottom of distribution media 1 31"
B. Periodically saturated soil/bedrock 48"
C. System separation 17
ce separation* 1 24"
*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.
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MINNESOTA POLLUTION
CONTROL AGENCY
520 Lafayette Road North
St. Paul, MN 55155-4194
Sewage tank
maintenance reporting form
Subsurface Sewage
Treatment Systems (SETS) 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 sewage tank
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 (mm/dd/yyyy): 12/1/2023 Reason for maintenance: Compliance Inspection
Property address: 750 Hackmore Dr. Pnrral in
City: _ Eagan
Property owner's name:
Julie Yakovlove
Property -owner's address (if different):
City:
Phone number: 651-206-8076
State: MN. Zip code: 55123
Zip code:
Email address: ytroopera-aol.com
1. Did you measure the accumulation of scum and sludge? ❑ Yes ❑ No (tank(s) pumped withrn,t maaci!rinn)
State:
Tank (check if present)
® Se tic/holdin tank #1
Scum
0"
Slud e
1 g
Operating depth
Percent full
® Septic/holdingSeptic/holding tank #2
0"
011
❑ Pretreatment tank
❑ Pump tank
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, (Pant owner's name) , refuse to allow the removal of the solids and liquids through the maintenance
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 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.
Owner's signature: _ Date (mm/dd/yyyy):
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Property address: 750 Hackmore Dr.
City: Eagan
State: MN.
Parcel ID:
Zip code: 55123
5. Is the tank designed as a leaky tank? (Example: seepage pit, cesspool, drywell, leaching pit)
Tank #1: ®Yes ❑ No Verification method used: Dug open camera drove pipe into dirt bottom
Tank #2: ® Yes ❑ No Verification method used: Drove pipe into dirt bottom camera
6. Is there evidence of the followina?
hole coverisTank
Tank check if resent
leaks belowthe
desi ned o eratin de th
Tank leaks above the
desi ned o eratin de th
cked, unsecured, or
struuunsound
® Se tic/holdin Tank #1
® Yes ❑ No
® Yes ❑ No®
ji
es ® No
Se tic/holdin Tank #2
® Yes ❑ No
® Yes❑ Noes
No
❑ Pretreatment Tank
❑ Yes ❑ No
❑ Yes ❑ No
El Yes El No
❑ PumpTank
El Yes El No
❑ Yes ❑ No
❑Yes ❑ No
Describe detail for any "Yes"
Stave tank and cesspool
Stave tank and cesspool
7. How many gallons of septage were removed?
Tank #1: 1000 Tank #2: 1000 Pretreatment Tank: Pump Tank:
8. Where was the septage taken? ® Wastewater treatment facility ❑ Land application ❑ Other
Explanation (Facility name/Site #): Blue Lake Treatment
9. 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 ❑ Baffle(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 t [I Repairs declined by owner:
Additional comments or suggestions for owner's consideration
Pumping record
I personally conducted the work 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(cDgmail.com
Employee's signature: Matt Mckinley
Employee information
Print name: Matt Mckinle
Certification number: (if applicable): 8067
Phone number: 952-440-1800
Date (mm/dd/yyyy): 12 / 1 /2023
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Property address: 750 Hackmore Dr. Parcel ID. -
City: Eagan State: MN. 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 (wq-wwists4 31 b). This form can be
found on the MPCA website at https://www.pca.state.mn.us/water/service-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): 12/1/2023
❑ 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
Groundwater." ®Yes`" El No
The SSTS has a sewage tank that leaks below the designed operating depth - "Failure to Protect
Groundwater."
® Yes''` ❑ No
The SSTS presents a threat to public safety by reason of structurally unsound (damaged, cracked, or ❑ 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 Mckinle
Certification number: 8067
I personally conducted the work described above as a Designated Certified Individual of a Minnesota -licensed SSTS Maintenance
Business. I 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 Mckinl
Date (mm/dd/yyyy): 12/ 1 /2023
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