4875 Pilot Knob Rd - Septic Mantenance Form 2024-05-20Mi MINNESOTA
POLLUTION
J
CONTROL
AGENCY
520 Lafayette Road North
it. Paul, MN 55155-4194
Compliance inspection report form
Existing Subsurface Sewage Treatment System (SSTS)
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 https://www.pca.state.mn.us/sites/default/files/wq-wwists4-31a.pdf.
Property information Local tracking number:
Parcel ID# or Sec/Twp/Range: 100330075013 & 100340050 Reason for Inspection Property Transfer
Local regulatory authority info: Dakota County
Property address: 4875 Pilot Knob Rd, Eagan, MN 55122
Owner/representative: Ralph & Shannon Scarfone Owner's phone:
Brief system description: Gravity Trenches 180' ST: 1200ga1.
System status
System status on date
® 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.)
*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 (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 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
1 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: Bohn
Well
Drilling Co.
Inspector
signature:
Joey
Menden
has been electronically signed)
(This document
Certification number: 1043
License number: C6844
Necessary or locally requi
red supporting documentation (must be attached)
Phone: 952-445-4809
❑ Other information (list):
® Soil observation logs ®System/As-Built ®Locally required forms ❑Tank Integrity Assessment ❑Operating Permit
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Property Address: 4875 Pilot Knob Rd. Eagan, MN 55122
Business Name: Bohn Well Drilling Co.
1. Impact on public health —Compliance component #1 of 5
Compliance criteria:
System discharges sewage to the ❑Yes' ®No
ground surface
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 safettr.
Describe verification methods and results:
Date: 5-.7�L ��4
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 tanks) leak below their
designed operating depth?
If yes, which sewage tanks) leaks:
Attached supporting documentation:
❑ Yes' ®No ®Empty tanks) viewed by inspector
Hennes Septic
Name of maintenance business: Pumping
❑ Yes' ®No License number of maintenance business: L486
Date of maintenance: s'a�-k�U
❑ Existing tank integrity assessment (Attach)
Date of maintenance
(mm/dd/yyyy): (must be within three years)
Any "yes" answer above indicates the system
is failing to protect groundwater.
Describe verification methods and results:
(See form instructions to ensure assessment complies with
Minn. R. 7082.0700 subp. 4 B (1))
❑ Tank is Noncompliant (pumping not necessary —explain below)
❑ Other:
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Property Address: 4875 Pilot Knob Rd
Business Name: Bohn Well Drilling Co.
MN 55122
Date: �-
5. Soil separation — Compliance component #5 of 5
Date of installation 05/01/1977
(mm/dd/yyyy)
Shoreland/Wellhead protection/Food
beverage lodging?
Compliance criteria (select one):
5a. For systems built prior to April 1, 1996, and
not located in Shoreland or Wellhead
Protection Area or not serving a food,
beverage or lodging establishment:
Drainfield has at least atwo-foot vertical
separation distance from periodically
saturated soil or bedrock.
5b.Nnn-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 athree-foot vertical
separation distance from periodically
saturated soil or bedrock.*
❑ Unknown
❑ Yes ®No Attached supporting documentation:
® Soil observation logs completed for the report
❑ Two previous verifications of required vertical separation
® Yes [:]No* ❑ Not applicable (No soil treatment area)
❑ Yes ❑ No*
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:
Indicate de the or elevations
May
V
Bottom of distribution media
Alb
B.
Periodically saturated soil/bedrock
>1a
C.
System separation
:51
D.
Required compliance separation*
Zk4
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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wq-wwists4-316 4/28/2021 Page 4 of 4
Property Address:
Business Name:
4875 Pilot Knob Rd. Eagan, MN 55122
Bohn Well Drilling Co.
3. Other compliance conditions —Compliance component #3 of 5
Date:
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
Is the system required to employ a Nitrogen BMP specified in the system design? ❑Yes ❑ No
BMP =Best Management Practices) specified in the system design
If "yes", A below is required
If "yes", B below is required
!f 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
https://www.pca.state.mn.us 651-296-6300
wq-wwists4-316 4/28/2011
❑ Operating permit (Attach) ❑
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Page 3 of 4
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Sewage tank
520 Lafayette Road North
St. Paul, MN 55155-4194
maintenance reporting form
Subsurface Sewage
'treatment Systems tooS) Program
Doc type: Compliance and Enforcement
Purpose: Management and maintenance of Subsurface Sewage Trea#ment Sysfems (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 maybe 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
Aft 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 (mmlddlyyyy}:
Property address:
City:
Property owner's name:
Property -owner's address (if different):
City;
State:
Phone number: Email address:
1. Did you measure the accumulation of scum and sludge? 0 Yes
Zip code:
No (tank(s) pumped without measuring)
Tank check if resent
Scum
Slud e
O eratin depth
Percent full
El Septic/holding tank #1
❑ Septic/holdingSeptic/holding tank #2
ElPretreatment 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, _� ,refuse to allow the removal of the solids and liquids through the maintenance
(Print owner's name)
hale. 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 (mmlddlyyyy):
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Property address: `% F5 F t )6 �� 1VrZ
City: State:
5. is the tank designed as a leaky tank? (Example: seepage pit, cesspool, drywell,
Tank#1: []Yes o Verification method used: P1�Pv jk.e l�l�. ((
Tank #2: ❑ Yes ❑ No Verification method used:
6. !s there evidence of the following?
Parcel ID:
Zip code:
pitJ
(
Maintenance hole
cover is
Tank leaks below
the
Tank leaks above the
damaged, cracked,
unsecured, or
Tank check if resent
desicined overatino de th
desi ned overatina
de th
a ars to be structuraliv
unsound
Septic/holdingSeptic/holding Tank #1
El
Yes XNo
Yes
No
❑ Yes
A
No
❑
Se tic/hoidin Tank #2
❑
Yes
o
I❑Yes
❑
No
❑Yes
❑
No
❑
Pretreatment Tank i
❑
Yes
❑
No
I ❑
Yes
❑
No
❑ Yes
❑
No
❑
Pump Tank i
❑
Yes ❑
No
❑
Yes
❑
No
❑ Yes
❑
No
Describe
detail for any °Yes" j
_
j
7. How many gallo of septage were removed?
Tank #1: Tank #2: Pretreatment Tank: Pump Tank:
8. Where was the septage taken? Wastewater treatment facility ❑ Land application ❑ Other
Explanation (Facility name/Site
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 troubieshooting and minor repairs completed or declined by owner:
❑ Troubleshooting and repairs conducted: ❑ Repairs declined by owner:
Additional comments or suggestions for owner's consideration:
Pumping record
1 personally conducted the work described above on behalf of aMinnesota-licensed SSTS Maintenance Business, in compliance
with Minnesota Rules Chapters 7080 — 7083:
As a nonceitified individual who has received proper training, daily work review, and periodic observation, or
As a designated certified individual of the business listed below.
B typing/signing my name below, 1 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 ,
Business license number:
Email: A h
Employee's signature:
Employee information
Certification number: (if applicable): _
Phone number: _
Date (mm/ddiyyyy):�
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