4875 Pilot Knob Rd - Septic Maintenance Form 2015-07-14 tutinnesat�aPoltut�n �01�'1�33�1c�CiC�' ftlS�J�Ct1U1'1 FOf"C11
Contrc>I�4gency
��������,�� Existing Subsurface Sewage Treatment Systerns
s�.�au�.n+w sst�s-��� (SSTS)
Dac Type:Complrance and Enforcement
Instructions: Inspection resufts based on Minnesota Po{lution Control Agency(MPCA) For local tracking purposes:
requirements and attached foi�ms-additional iocai requirements may also apply.
Submi#compieted form to Locat Unit of Government(LUG)and system owner
within 15 days
System Status
System status on date(mm/ddtyyyy): 7/74/2Q15
� Campliant-Certifica#e o#Campiiance ❑ Noncompiiant- Natice of Noncompliance
(Valid for 3 years from report date, unless shorter fime (See Upgrade Requirements on page 3)
frame outiined in Local Ordinance.}
Reason(s)for noncompliance(check all applicable)
❑ Impact on Public Health(Compliance Component #1)—Imminent fhreat to public heaJth and safety
❑Other Compliance Gonditions(Compliance Component#3}—/mminent thr�at to public heaith and safefy
❑Tank Integri#y(Compliance Component #2)—Failing to protect groundwater
❑Other Compliance Conditions(Compliance Componenf#3)—Failing to profect groundwater,
❑Soii Separation(Compliance Component #4)—Failing to protect groundwater
❑Qperafing permittmanitoring plan requirements(Compliance Component #5)—Noncompliant
P1"Op@I'ty 111fOCtlld'�lOtl Parcel iD#or Sec/1'wp/Range: 10033Q075p13&100340050012
Property address: 4875 Pilat Knob Rd. Reason for inspection: Property Transfer
Property owner. Carol Cafarelli Owner's phone: (651)331-9480
or
Owner's representafive: Representative phone:
Local regulatary authority: City of Eagan Regulatory aufharity phone: 651-875-5675
Brie#system description: Drainfield
Gomments or recommendations:
Certification
!hereby certify that all the necessary information has been gafhered to determine the compfiance stafus of this system.No
defermina6on of fufure system performance has been nor can be made due to unknown condi6ons during system construction,
passible abuse of the system,inadequate mainfenance, or futur�water usage.
Inspector name: Gary M.Bohn Certifica#ion number: 959
Business name: Bohn Well D ' 'n Co. �ieense number: 1043
Inspector signature: �' Phone number. {952)445=4809
Necessary or Locally Required Attachments
�Soil boring logs � SystemlAs-built drawing ❑Forms per local ordinance
❑4ther information(iist):
www.pca.state.mn.us • 651-296-b300 . 800-657-3864 • TTY 651-282-5332 or 8U0-657-3864 • Available in altemative formats
wq-wwists4-3i • 11Z4/i2 Pqge 1 af 3
Property address: 4875 Pilot Knob Rd. lnspector initials/�ate: 07-14-15
1. (mpdCfi 011 PUbIiC Health—Comptiance component#1 of 5
Com liance criteria: Verification method(s}:
System discharge sewage to the ❑Yes � No � �earched for surface outiet
_ground surface. � Searched for seeping in yard/backup in home
Sysiem discharge sewage to drain tile ❑Yes �No � ��ssive ponding in soil system/D-boxes
❑ Flomeowner testimon (See CommantslExplanafion)
or sur�ace waters.
Y
° r al s stem
❑ Black soil"above soil dispe s y
System cause sewage backup into ❑Yes �tVo
dwe8ing or esfablishment. ❑ Sysfem requires"emergency"pumping
---- ----- ---- ❑ Performed dye#est
Any"yes"answer above indicates the sysfem is ❑ Unable to verify(See Comments�F�cplanafion)
an lmminent Threat ta Public Health and Safety. ❑ Other methods not listed(See Comments/Exp►ana#ion)
Gomments/Explanation:
2. Tdnk Integt'ity—Compliance component#2 of 5
Com liance criteria: Verification method(s):
System consists of a seepage pit, ❑Yes � No � Probed tank(s)bottom
cesspool,drywell,or leaching pit. � Examined consfruction records
Seepage pifs mee5ng 7080.2550 may be � Examined Tank Integrity Form(Attach)
com lianE if sllowed in/ocal ordinance.
❑ Observed liquid level below operating depth
Sewage tank(s)leak below their ❑Yes �Mo ❑ �xamined errtpty(pumped)tanks(sj
desi ned o eratin de th.
If yes,which sewage tank(s)leaks: ❑ Probed outside tank(s)for"black soil"
�111,Y "y�s"at1SWeP abOVe ilidiCates the �� ❑ Unable to verify(See Comments/Explanation)
sysfem is Failing to Protect Groundwater. ❑Other methods not listed(See Corrrments/Exp�anation)
Comments/Explanation;
3. Other COtnplidnCe COnditiOns—Compliance component#3 of 5
a. Maintenance hole cavers are damaged,cracked,unsecured,or appear to structurally unsound. p Yes" �No ❑Unknown
b. Other issues(elecerical hazards,etc.)to immediately and adversely impac#public health or safety. ❑Yes" �No ❑Unknown
*System is an imminent threat fo publfc healfh and safety
F.acplain:
c. System is non-protective ofi ground water for other conditions as determined by inspector : D�'es" �No
*Sysfem is faiting to profect groundwafer -
Explain:
www.pca.state,mn.us • 651-296-6300 • 800-857-3864 • TTY 651-282-5332 or 800-657-3$64 • Available in attemative formats
w9-wwists4-31 • 1/14/12 PQge 2 of 3
Property address: 4875 Piiot Knob Rd. inspector initia{slDate: 07-14-15
4. Soil Sepdt'ation—Compliance component#4 of b
Date of instatlation: 1977 ❑ Unknown Verification method{s):
�od�nan?dtWellhead protectionlFood Beverage Q Yes � No Soil observation does nof expire.Previous soil
g g observa6ons by hvo independent parties are sufficient,
ComplianCe Criteria: unless sife conditions have been altered or local
requirements differ.
Forsystems buitt pxiorto April 1, 1996, and �Yes ❑No
not located in Shoreland orWellhead � Conducted soil absen►ation(s)(Attach baring logs)
Protection Arsa or nof serving a food, ❑ Two previous verifrca#ions(Altach boring.lags)
bevsrage orlodging establishment.
❑ Not applicable(Hotding fank(s),no drainfield)
Drainfield has at least a two-foot verticai ❑ Unable to verify(See Commenes/E�cp/enation)
separation distance from periodicaHy
saturated sail or bedrodc. ❑ Other(See Comments/Explanation)
Nan pedormance systems built Apri!1, ❑Yes ❑No CommenfslExplanafion:
?998,or later or for non-performance
systems located in Shareland or Wellhead
Protection Areas or serving a foad,
beverage,or lodging establishment.
�rain�eid has a th�ee-foot vertical
separation disfance from periorlically
saturated soil or bedrock.*
Experimental" "Other'; or Perfarmance" p Yes ❑No lndicate dep#hs of elevations
sysfems built under pre-2008 Rules;Type 1V
or V sysfems built under 20D8 Rules(7080. A. Bottom of distribution media 40"
2350 ar 7080.24D0 (Advanced Inspedor
license requiredj B. Periodical saturated soiUbedrock 72"
Drainfieid meets the designed vertical C. S stem separation 32"
separation distance from periodically
saturafed soil or bedrock.
D. Re uired com liance se aration" 24"
Any "no"answer above indicafes fhe system is *(�ay be reduced up to 15 percent if ailowed by Local
Failing to Protect Groundwater. Ordinance.
5. Operating Permit and Nitrogen BMP*—Compliance component#5 of 5 � Not applicable
Is the system aperated under an Operating Permit? �Yss 0 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
lf the answer to both questians is "no'; this section does not need to be campleted.
Compliance criteria
a. Operating Permif number:
Have the C? erafin Permit r uiremen#s been met? C7 Yes ❑ No
b. Is the re uired nitro en BMP in lace and ro erl functionin ? ❑Yes ❑No
Any "no"answer indicates Noncompliance.
Upgrade Requirements(Minn.Stat§115.55j An imminent threaf to public hea/th and safery(ITPHS)must be u�graded,rep/aceo;or its use
discontinued wifhin ten months of receipt of this notice or within a shorier penod if required by loca/ordinance.lf the system is failing fo protect
ground wafer,fhe sysfem must be upgradeci,replaced,or its use disconUnued wiffiin the time required by loca!ordinance.!f an exis#ing system
is nof failing as defrned in 1aw,and has al/east hvo feet of design soi!saparafion,then the system need not bs r�pgraded,repaired,rep/aced,or
ifs use discontinued,notwiPhstanding any loca!ordinance that is more strict. This provision does not appty to systems in shore/and areas,
Wellhead Protection Areas,or thase used in connection with food,beverage,and todging establishmenfs as defined in/aw.
www.pca.state.mn.us � 651-296-6300 • 800-657-3864 • TTY b51-282-5332 or 800-657-3864 • Avaitable in altemative formats
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