750 Hackmore Dr - Septic Abandonment 2024-09-09Minnesota Pollution SETS Abandonment
Control Agency
520 Lafayette Road North Reporting Form
St, Paul, MN 55155-4194
Subsurface Sewage Treatment Systems (SSTS) Program)
Instructions
This form is offered to meet the abandonment requirements of Minn. R. 7080.2500 and Disclosure Requirements of Minn. Stat.
§ 115.55, subd. 6. Future water supply well placement can also be affected by an abandoned SSTS.
The use of this form is not mandatory; however the information on this form must be submitted to the local government unit (LGU)
within 90 days after the abandonment, This form may be completed by a certified SSTS practitioner or by an individual who has
direct knowledge of how the system was abandoned.
Property Information
Date of abandonment: 9-9-2024 Reason for abandonment: Demo
Property owner name(s): Chris Lawrence - - -- - -- -
Property owner's address: 1448 Kingswood Ponds Rd. — - M -
State: N. Zip. 55122
City: Eagan _ - _ - _ Site address (if different): 750 Hackmore Dr.—
City: Ea_an State: MN. Zip: _55123
Compliance Information
1. All solids and liquids removed from ail tanks? ® Yes ❑ No
Disposal Site: Blue Lake Treatment
2. All electrical devices and devices containing mercury removed? ❑ Yes ® No
Disposal Site: N/A
3. All underground sewage tanks crushed and filled with soil or rock material? ❑ Yes ® No or
Removed and disposed off site? ® Yes ❑ No
Disposal Site: Mueller and Sons 5215 Dahlgren Rd., Chaska MN., 55318
4. Contaminated materials* removed and disposed off site? ® Yes ❑ No
Disposal Site: Mueller and Sons 5215 Dahlgren Rd Chaska MN., 55318
5
All underground cavities** crushed and filled with soil or rock material? ® Yes ❑ No or:
Removed and disposed off site? ❑ Yes ❑ No
Disposal Site:
6. Future discharge to system permanently denied? ® Yes ❑ No
Method(s) used: Tanks pumped, removed and hauled off site. Abandonment.
*Contaminated materials = Distribution media, soil or sand within three feet of the system bottom, distribution pipes, geotextile
fabric/rosin paper/straw, tanks, contaminated soil around leaking tanks, any soil that received sewage
from a surface failure (7080.2500 subp.3).
-Underground cavities = Cesspools, leaching pits, drywells, seepage pits, vault privies, pit privies, pump chambers
(7080.2500 subp. 1). Does not include chamber media, drop boxes, or distribution boxes.
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Map
Include location of building sewer, septic tank(s), soil dispersal system, cesspools, seepage pits, and other pits. Also
include a permanent reference point(s) and dimensions.
T North
Certification
I hereby certify the system was abandoned in accordance with Minn. R. 7080.2500 and any local requirements.
Name (please print): Matt Mckinley Title: Owner (Mike's Septic and Mckinley Sewer)
Address: 16961 Mushtown Rd.
City: Prior Lake State: MN. Zip: 55372
Phone: 952-440-1800 License # if applicable): 2899
Date: 9-9-2024 Signature: � �d'J`�•�'�i </ \
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MINNESOTA POLLUTION
CONTROL AGENCY
520 Lafayette Road North
St. Paul, MN 55155-4194
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): 9/9/2024
Property address: 750 Hackmore Dr.
City: Eagan
Property owner's name: Chris Lawrence
Property -owner's address (if different):
City: Eagan
1448 Ki
Reason for maintenance: Demo
Parcel ID:
State: MN. Zip code: 55123
Ponds Rd.
State: k
Phone number: 612-812-6503 Email address
1. Did you measure the accumulation of scum and sludge? ® Yes
J. Zip code: 55122
cjlawrence@comcast.net
❑ No (tank(s) pumped without measuring)
Tank (check if present) Scum Sludge Operating depth Percent full
® Septic/holding Septic/holdingtank #1 0" 2"
® Septic/holding tank #2 0" 0"
❑ Pretreatment tank
❑ Pump tank I
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:
Abandonment tanks dug out of ground.
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.
1, , refuse to allow the removal of the solids and liquids through the maintenance
(Print owner's name)
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 (mimfddlyyyy):
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Property address: 750 Hackmore Dr. Parcel ID:
City: Eagan State: MN. 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: Abandonment
Tank #2: ® Yes ❑ No Verification method used: Abandonment
6. Is there evidence of the following?
Tank check if resent
Tank leaks below the
designed operating depth
Tank leaks above the
designed operating depth
' Maintenance hole cover is
damaged, cracked, unsecured, or
appears to be structural) unsound
® Septic/holding Tank #1
® Yes
[-]No
® Yes
[_]No
❑Yes ® No
® Septic/holding Septic/holdingTank #2
® Yes
❑ No
® Yes
[:]No
❑ Yes ® No
❑ Pretreatment Tank
❑ Yes
❑ No
❑ Yes
❑ No
❑ Yes ❑ No
❑ Pump Tank
❑ Yes
❑ No
❑ Yes
❑ No
❑ Yes ❑ No
Describe detail for any "Yes"
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: Abandonment
10. List any troubleshooting and minor repairs completed or declined by owner:
F-1 Troubleshooting and repairs conducted: 1 ❑ Repairs declined by owner:
Additional comments or suggestions for owner's consideration:
These tanks abandoned dug out and disposed of.
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 Employee information
Company name: Mike's Septic and Mckinley Sewer Print name: Matt Mckinley
Business license number: 2899 Certification number: (inapplicable): 8067
Email: mckinleysewer@gmail.com Phone number: 952-440-1800
Employee's signature: Matt Mckinley
Date (mm/dd/yyyy): 9/9/2024
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