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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. www.pca.state.mn.us 651-296.6300 800-657-3864 TTY 651.282.5332 or 800-657-3864 • Available in alternative formats wq-wwists4-03 • 11121108 Page i of 2 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 </ \ www.pca.state.mn.us 651-296-6300 800-657-3864 TTY 651-282-5332 or 800-657-3864 • Available in altemative formats wq-wwists4-03 • 11121108 Page 2 of 2 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): www.pca.state.mn.us 651-296-6300 800-657-3864 Use your preferred relay service Available in alternative formats wq-wwists4-38 • 4/28/21 Page 1 of 3 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 www.pca.state.mn.us 651-296-6300 800-657-3864 Use your preferred relay service Available in alternative formats wq-wwists4-38 • 4/28/21 Page 2 of 3