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1674 Riverton Pt - MPCA Septic Compliance Form Minnesota Poll oAUG 2 o 2009 Compliance Inspection Form Control Agency Existing Subsurface Sewage Treatment Systems (SSTS) 520 Lafayette Road North Doc Type: Compliance and Enforcement St. Paul, MN 55155-4194 Instructions on page 6 Summary Form (Completed form must be submitted to the local unit of government within 15 days.) Parcel number: 101438503001 For Local Tracking Purposes: System status: (Compliant 0 Noncompliant (based on all compliance requirements) Property Information Property owner name(s): Craig Hamilton Property owner phone: Property address: 1674 Riverton Point, Eagan 55122 Property owner address (if different): County: Dakota Permitting authority: City of Eagan Date system constructed: Reason for inspection: Property Transfer System Description / Brief system description: .2 G-e T,,,Ir c/ 401n 1n /;W /V Local permit number: Number of bedrooms: Design flow rate: Is the system: In Shoreland area? *Yes 0 No In Wellhead Protection Area? 0 Yes ® No An U.S. Environmental Protection System serving a Minnesota Department Agency (EPA) Class V Injection Well? 0 Yes 11 No of Heath (MDH) licensed facility? D Yes I No Compliance Status (Based on state requirements - additional local requirements may also apply.) Based on the information gathered and reported on attached forms, the compliance status of this system is (check one): Certificate of Compliance - valid until (3 years from date of report): 9- itf ? Notice of Noncompliance - For Noncompliant systems: The reason for noncompliance is: This noncompliant system is classified as (check one below): ? Imminent threat to public health & safety D Failing to protect ground water 0 Not in compliance with operating permit Certification I 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. Name: Gary M Bohn Certification number 949 Business license name and number Bohn Well Drilling Co #1043 or Name of local unit of government: Signature: c J - Date: 8'- /Y O'! Required Attachments Hydraulic Performance 3 Tank Integrity D Operating Permit Form (N applicable) Soil Boring Logs 10 Soil Separation System drawing/As-built drawing 0 Any local requirements that are different from what is required on this form D Other information (fist): Upgrade Requirements (derived from Minn. Stat. § 115.55) An imminent threat to public heal h and safely (ITPHS) must be upgraded, replaced, or its use discontinued within ten months of receipt of this notice or within a shorter period if requ tired by focal ordnance. 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 ordnance. N an existing system is not failing as defined in law, and has at 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 toes not apply to systems in slorefend areas, Wellhead Protection Areas, or those used in connection with food, beverage, and JbdWng establishments as defined in law. www.pca.state.mn.us • 651.296-6300 • $00-657.3364 TTY 651-282-5332 or 800-657-3864 • Available fin alternative formats wq-wwtsts4.31 • 4/24109 Page I of 8 Parcel number: 101436503001 System status: a Compliant ? Noncompliant (as determined by this form) Hydraulic Performance and Other Compliance - Compliance Inspection Form for Existing SSTS Compliance Issue #1 of 4 Date of observation: I?- / 4/ o Reason for observation: Property Transfer This form expires upon next inspection or in three years, whichever occurs first: Compliance questionsicriteria: (Required) Verification Method*: (Optional) (Check the appropriate box) (Check the appropriate box) Does the system discharge sewage to the ? Yes ¦ No 0 Searched for surface outlet ground surface? ? Performed hydraulic test Does the system discharge sewage to drain ? Yes ONO tile or surface waters? S Searched for seeping in yard Does the system cause sewage backup ? Yes ® No ? Checked for backup in home into dwelling or establishment? ? Excessive ponding in soil system/D-boxes Do other situations exist that have the ? Yes No ? Homeowner testimony potential to immediately and adversely impact or threaten public health or safety ? Examined for surging in tank electrical, unsafe covers, etc.)? ? "Black soil" above soil dispersal system Any "yes" answer Indicates that the system is an imminent threat to public health and safety. ? System requires "emergency' pumping ? Performed dye test Does the system pose a threat to ground ? Yes 0 No water for any conditions deemed non- protective ? Other: as determined by the inspector? "Yes" indicates that the system is failing to protect ground water. If "yes". describe the condition noted: No standard protocol exists. This list is not exhaustive, in sequential order, nor does it indicate which combinations are necessary to make this determination. Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's (MPCA) Compliance Inspection Form for Existing Subsurface Sewage Treatment Systems. Observations, interpretations, and conclusions must be completed by an inspector. Completed form must be submitted to the local unit of government within 15 days. Property owner name(s): Craig Hamilton Property address: 1674 Riverton Point, Eagan 55122 Property owner's address (ii different): County: Dakota Property owner phone: I hereby certify that ! personally made the observations, interpretations, and conclusions reported on this form and that they are correct. Name: Gary M Bohn Certification number: 949 Business license name and number: Bohn Well Drilling Co #1043 or Name of local unit of government: Signature: _ /,-t d,_ _ Date: 4 L) www.pca.state.mn.us • 651-296-6300 • 800.657-3864 TTY 651-282-5332 or 800-657-3864 • Available in alternative formats wq-wwists4-31 • 4/24/09 Page 2 of 8 Parcel number: 101438503001 System status: ® Compliant ? Noncompliant (as determined by this form) Tank Integrity and Safety Compliance - Compliance inspection Form for Existing SSTS Compliance Issue #2 of 4 Date of observation: 9 Reason for observation: Property Transfer This form expires on (three years): k- /_j _ 2-Compliance questionsicriteria: (Required) Verification Method"*: (Optional) (Check the a rate box) (Check the appnapriate box) Does the system consist of a seepage pit*, ?Yes ~ No ®Probed tank bottom cesspool, d ell or leaching pit? Do any sewage tank(s) leak below their ? Yes U No ? Observed low liquid level designed operating depth? ? Examined construction records If yes, identify which ? Examined empty (pumped) tank sewage tank leaks. Any "yes" answer Indicates that the system is falling to protect ? Probed outside tank for "black soil" ground water. ? Pressure/vacuum check ? * Seepage pits meeting 7080.2550 may be compliant if allowed Other: in ordinance by local permitting authority. No standard protocol exists. This list is not exhaustive, in sequential order, nor does it indicate which combinations are necessary to make this determination. Safety Check 1. Are maintenance hole covers damaged, cracked, or appeared to be structurally unsound? ? Yes* ® No 2. Were maintenance hole covers replaced in a secured manner (e.g., screws replaced)? A Yes ? No* 3. Was secondary access restraint present (safety pan, second cover, or safety netting) - highly recommended. ? Yes ® No 4. Are other safety/health issue present? ? Yes* ® No Explain: *System Is an imminent threat to public health and safety. Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's (MPCA) Compliance Inspection Form for Existing Subsurface Sewage Treatment Systems. Observations, interpretations, and conclusions must be completed by an inspector, maintainer, or service provider. Completed form must be submitted to the local unit of government within 15 days. Property owner name(s): Craig Hamilton Property address: 1674 Riverton Point, Eagan 55122 Property owner's address (if different): County: Dakota Property owner phone: I hereby certify that I personally made the observations, interpretations, and conclusions reported on this form and that they are correct. Name: Gary M Bohn Certification number: 949 Business license name and number: Bohn Well Drilling Co 01043 or Name of local unit of government: Signature: 2/,-fem. Date: www.pca.state.mn.us • 651.296.6300 • 300-657-3864 • TTY 651-232-5332 or 800-657-3364 • Available inalternative formats wq-wwists4-31 • 4/24/09 Page 3 of 8 Parcel number: 101438503001 System status: AN Compliant ? Noncompliant (as determined by this form) Soil Separation Compliance and Other Compliance - Compliance Inspection Form for Existing SSTS Compliance Issue #3 of 4 Date of observation: / ~1- O 9 Reason for observation: Property Transfer This information on this form does not expire. Compliance questionsicriteria: (Required) Verification Method**: (Optional) (Check the a rate box) (Check the appropriate box) For systems built prior to April 1, 1996, and not Conducted soil observation(s) (attach boring logs) located in Shoreland or Wellhead Protection Area or not serving a food, beverage or ? Two previous verifications (attach boring logs) lodging establishment: ~ Other: 7,o- 4 Does the system have at least a two-foot Tr o.+ s ~a 41 n - 3 6 110 vertical separation distance from periodically saturated soil or bedrock? ? Yes ? No For non-performance systems built April 1, 1996, or later or for non-performance systems located in Shoreland or Wellhead Protection Soil observation does not expire. Previous observations Areas or serving a food, beverage or lodging by two independent parties are sufficient, unless site establishment: conditions have been altered. Does the system have a three-foot vertical separation distance from periodically saturated soil or bedrock?* Yes ? No For reduced separation distance systems (i.e., "performance" systems under old 7080.0179 or * May be reduced by up to 15 percent if allowed in local Type IV or V system under new 7080. 2350 or ordinance. 7080.2400): No standard protocol exists. This list is not exhaustive, Does the system meet the designed vertical in sequential order, nor does it indicate which separation distance from periodically saturated combinations are necessary to make this soil or bedrock?* 0 Yes 0 No determination. Any "no" answer indicates that the system Is falling to protect ground water. Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's (MPCA) Compliance Inspection Form for Existing Subsurface Sewage Treatment Systems. Observations, interpretations, and conclusions must be completed by an inspector or designer. Completed form must be submitted to the local unit of government within 15 days. Property owner name(s): Craig Hamilton Property address: 1674 Riverton Point, Eagan 55122 Property owner's address (if different): County: Dakota Property owner phone: I hereby certify that I personally made the observations, interpretations, and conclusions reported on this form and that they are correct. Name: Gary M Bohn Certification number: 949 Business license name and number: Bohn Well Drilling Co #1043 or Name of local unit of government: Signature: 2 Date: 8 y- o j? 47 www.pca.state.mn.us • 651-296-6300 • 800-657-3864 TTY 651.282-5332 or 800.657.3864 • Available in alternative formats wq-wwtsts4-31 • 4/24/09 Page 4 of 8 r k Soil Boring Log Date: Project Location: Twp. Eagan Client: Craig Hamilton Borings Made By: Address: Ciaro M $ohw license #1043 City State Zip Boring Method: Auger Pit Probe Other Color Classification System: Musef Other Boring Number Boring Number Surface Elevation Surface Elevation Soil Typ at System Depth Soil Typ at System Depth Depth Texture Color Depth Texture Color (Feet) (Feet) Zi - /p u,,., '7, cyr t- y 1- s~., ply iAy 41 z- s~r.11, /ng..,.. 7~i• y 2- 3 - 3-- 4- 4- 5- 5- 6- 6- 7-1 7--- Structure: Blocky Platy Prismatic None Structure: Blocky Platy Prismatic None Slope: % Slope: % End of Boring at feet End of Boring at feet Standing water table Yes No Standing water table Yes No Present at feet of depth Present at feet of depth hours after boring hours after boring Mottled Soil: Mottled Soil: Observied at feet of Depth Observied at feet of Depth Not present in boring hole Not present in boring hole Observations or Comments: Observations or Comments: . i. T Itp LD 1~ M