4875 Pilot Knob Rd - Septic Maintenance Form 2004-02-11?
2/25/02 WaterkWastewaterISf54.31
Compliance Inspection Farm for Existing '
? Individual Sewage Treatment Systems Minnesota Pollutlon
? Control Agency
'ompfeUOn of thls,form tulfllls t/ie minlmal requlrements af Mlnn Stat. § 115.55 (2001) and Mrnnesola R. ch. 7080 (199?. Pleese tefer
? looel ordinance§ for other requirements.or In(ormation; especi ally for compi(ance requirements tor bedroom additions.
Ggneral ,
Date^of Inspedion:' 2-11-04. ,:- Reason for inspectlon: sale
Home
PropertyOwner(s) ETizabeth Brandt T?1=phone(65'? 405-0861
k
Person requesting inspectton Telephone 651) 683-6801
SiteAddress 4875 Pilot Knob Road City Eagan ZipCode 55123
Fire No./ Parc01 No. County Dakota Township
_ .;:.Legal Description
Local Regulatory Authority
Datesystem constructed 1 977 System in Shoreland Area: yes ?Q ?ystem in Welihead
' Protection Area: yes no System serving a MDH licensed facility: yes no Local Permit #(if any) ?
Systems built prior to Aprll 1, 1996 and. not located In Systems iocatea in snoreiana or vveuneaa rroEernon
Shoreland or Wellhead Protedion Area or Serving a Food, Areas or Serving a Food, Beverage or Lodgtng
Beverage or Lodging Establishment Establishment, or systems Built after
March 31, 1996
Is the system an tmminent threat to o'ubltc health or
safeN7 (a yes answer /s an ITPHS.system)
- 0lscharge of sewage to the ground surtace? YES 0.
- Dlscharge of sewage to dra(ntile or surface waters7 YES 0
- Sewage backup Into dwelling? YES
= Sftuatfon with the potential to fmmediately and
aMersefy Impact or threaten public health or
safety7 YES ?
Is the svstem an imminent threat to outilic health
.
or safetv? (a yes answer ls an ITPNSSystem)
- Discharge of sewage to the ground surface7 YES NO
- Discharge of sewage to draintile or surface waters7.YE5' NO
- Sewage backup into dwelling? YES NO
- Sltuatiomwitfi the poCential to (mmediately and '
adversely Impact or threaten public health or
safety7 YES N0
Is #he svstem fafiina7 (a yes answer, ls a: failing system)
? • Less than 71N0 feet of verffcal separatlon between
='system bottom and saturated soll or bedrock7 -- YES 0
- A seepage p;t, c2espool, dr/well, or leaching pit? . YES L(?
Is the svstem non-comnltant? •
- Is the system regulated under a monitoring pian or
opereting permit? (if no, go to page 2) YES UO
-r( yes,
- Has the required monitoring taken place? YES NO
(ilno, the system is non-complying) , .
Does the monitoring Indicate thaf the systein meets
pertorm2nce expebtations? YES N0.
(Il no, ' fhe system (s non-complying)
Is the svstem failina? (a yesvnswerrsa fa//ingsystem)
- Less thari THREE feet of vertical separation between
- rystem bottom and saturated soil or bedrock7 YES PJO
- A seeoage pit, cesspool, drywell, or leaching pit7 YES NO
Is the svstern non-compliant?
- Is tho system regulated under a monitoring plan or
operating permft? (il no, go to page 2) YES NO
1I yes,
• Has the Tequired moNtoring laken place? YES NO
(If no, the system Is non-complying)
- Does the monitoring indicate that the system meets
performance expectations? YES
(II no, thv sysfem is non-complyfng)
NO
. Page 1 of 2 II?? APRv?-CV wis0ts4.
s
Property Owner(s •', Fire No./ parcel No.
t
System Comoonents (P/ease describe the system com onents and attach srle sketch slrowing system location).•
..... . A n r ,,,.9i'
' What methods.were used to make the determinatlons for the comoliance Insnection? (Note: No standardprotoco/exlsts,
s The following lisf is not exhaustive, or rn sequenG31 order nor indicates whrch cornbinations may necessary to make a determinat/on)
WateKight Wnk(s)
pr" Probed tank bottom
? Observed low liquid level
? EKamined const, records
• Examined empty (pumped) tank
o Probed outside tank for "black soil"
Mydratdlc Functioning
pII'5earched for surface outtet
? Performed hydraulic test
r,d-Searched for seeping in yard
O Checked for back-up in horne
o Fccessive ponding in soil system/D-boxes
Vertical Separation Distancegr-Conducted soil borings / r(
Depth to limiting layer,6A&t / Z
Depth to system bottom
o Examined records
O LGU Limitlny Layer VeriFlcatlon
? Ollier '
? Pressure/vacuum check
? Other
0- Homeowner testimony
C) Examined for surging in tank
q "Cilack soil':above soil systern
O O:her
Based on the compliance criteria, the system status Is; (check one) ? failing (to protect groundwater) ? an
Jmminent threat to public health or safety (Il"PHS), O non-compliant (monitoring issue) O compliant (none of the 3
pre.vious conditlons), Therefore, this document is a: JrCertifcate of Compliance ? IVotice of Noncompliance
Is this s stem an EPA Class V Injection Well? E) yes O no
Certification -
' I hereby certi(y asa staEe of Minnesota licensed Inspector and/or.Designer. I or Qualified Employee Inspector and/or Qualified Employee
; Designer I that I wnducted an Investigatlon that accurately determined the compliance staCUS of this system and that my recorded
; observations are accurate as of this date. No determination of future hydraulic performance has been nor can be made due to
unknown conditlons during system construction, abuse of the system, iradequate maintenance, or future water usage.
Inspector'sname(pr4nt) Bob Freiermuth Phone_651-437-5343
'License and/or Registratlon Number $18 _ Address 23620 Li1leheLA_ vg=,Hamptnn
Employed by Crwner r _ Address
Stgnature Data JEWA!X iny
UnnradeReqUirements fderived(1omMinnesotaStatutes§115.55)
An ITPHS must be upgraded, rep/aced, oriLS use discontinued within !en ntonths of receipt of tliis notice or withrn a shorter perlod if
required by loca/ ordinance. I(the system falls tu provide suffcientgroundwaterprotection, then the system nuist be upgraded,
? rep/aced, or /ts use discont/nued withrn the t/me required by ru/e or the /ocaF ordinvnce. /f an ex15tin9 systein is not fai/ing as defined in
law, and has at /east rivo feet of deskn soil separition, then the system necd not Ge upgradzd, repaired, replaced, or its use
`discontlnued, nolw/ths[anding any local ordlnance that is more strict. This does nvt apply to systzn rs in shore/and arevs, wef/head
protection areas, or those used in connection with foqd, beverage, and lodging estab/ishments a> defined in law.
'Suaq este'd:kttach m ents
:.;1) Site sketch could:aisolnclude:. well, well seCbadc to system, dweliing or other bmildings, tank(s),reserved soil treatment area,
' surface water and soll borin9 locations. Indude a5-bullt drawing if available.
'2)' Soll horing logs, Showing e5ch horizon. Indkate the texture, color; redoximorpfiic features depth to bedrock, standing water and
whether the material is fill.
3) A list of any and all requireinents of the Iocal ordinance thaC are differenC from Yhe state requireinents referred to on this form.
4) A homeowner survey of system performance, signed by the homeowner as being factual. .
5) Monltoring daW as appropriate.
Page 2 of 2
p
Date:
2-11-04
Customer Name: Elizabeth arandt
Street Address: 4875 Pilot,xnob Road _
City, State, Zlp: Eagan, MN 55123
Phone Num6er: 651-405-0861
COIYIf'ANY D15CLAIMER
Based on what we were able to observe and on our experience with on•site wastewater
technology, we submit this Onsite Sewage Treatment System Inspection Report based
on the present condition of the onsite sewaga disposal systEm.
Bob Freiermuth has not been retained to warrant, guarantee, or certify the proper
functioning of the system for any period of time in the future, Because of the numerous
factors (usage, soil characteristics, previous failures, etc.) which may affect the proper
operation of a septic system, as well as the inability of our company to supervise or
monitor the use or maintenance of the system; this report shall not be construed as a
warranty by our company that the systern will function properly for any particular
buyer, Bob Freiermuth hereby DISCLAIMS ANY WHRRANTY, either expressed or implied,
arising from the inspection of the septic system or this report. We are also not
ascertaining any affect the system is having on the graundwater.
Inspecting Company Phone 651 437•9605
Bob Freiermuth License No. 798
Customer Acknowledgement. ,
?-?•-•
?Gt./
I have studied.the information contained herein and ccrtify that my assessment is
honest, thorough, and to the Uest of my ability, correct.
Name:
Title:
? r