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1580 Letendre St - MPCA Compliance Inspection formFROM : Minnesota Pollution . Control Agency 520 Lafayette Road North St. Paul, MN 55155 ^4194 Parcel number 104490012102 Business license name and number Mendota Environmental L1718 Name of looaf unit of go Signature: Required Attachments ment: FAX NO. : 6514550483 Mar. 31 2010 03:48PM P2 Compliance Inspection Form Existing Subsurface Sewage Treatment Systems (SSTS) instructions on page 7 For Local Tracking Purposes: System status: 0 Compliant ® Noncompliant (based on all compliance requirements) Summary Form Property Information Property owner name(s): Estate of William J. Swart Property address: 1580 Letendre St. Eagan, MN 55121 Property owners address (If different): County: Dakota Property owner phone: 651 -403 -1645 Permitting authority: Ciiv s�f Ea„gan _ Date system constructed: 1952/1960's Reason for inspection: property transfer System Description Brief system description: Dry well system in front yard and second system in backyard Local permit number. Number of bedrooms; Design flow rate: Is the system: In Shoreland area? ❑ Yes ® No in Wellhead Protection Area? © Yes El No An U.S. Environmental Protection System serving a Minnesota Department Agency (EPA) Class V Injection Well? ❑ Yes El No of Heath (MDH) licensed facility? Q Yes ® 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): 0 Certificate of Compliance — valid until (3 years from date of report): ® Notice of Noncompliance - For Noncompliant systems: The reason for noncompliance is: dry well This noncompliant system is classified as (check one below): 0 Imminent threat to public health & safety ® Failing to protect ground water ❑ Not in compliance with operating permit Certification (Completed form must be submitted to the local unit of government within 15 days.) 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. Name: Frank Bakke Certification number. C4209 Date: 3/31/10 Inspector Complete: This Inspection Report is , pages long. Check compliance forms attached: Hydraulic Performance 183 Tank Integrity ❑ Soil Separation ❑ Operating Peirnit Form (if applicable) System drawing /As - built drawing 0 An assessment of any local requirements that are different from what is required on this form ❑ Soil Boring Logs 0 Abandonment form (if appropriate) ❑ Other information (list): Upgrade Requirements (derived ham Minn. Stet § 11555) 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 shO tar peffod nrequired by local ordinance. If the system Is failure 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 dsflned in law, and has at least two feet of design sof separation, then the system need not be upgraded, repaired. replaced, eras 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 feed, beverage, and lodging establishments as defined In law. FROM : Parcel number: 104490012102 System status: ❑ Compliant ® Noncompliant (es determined by this fora) Hydraulic Performance and Other Compliance Compliance Issue #1 of 4 Date of observation: 3/31/10 Reason for observation: property transfer This form expires upon next inspection or in three years, whichever occurs first 3(31/13 Compliance questionslcriteria: (Required) (Check the appro riate box Does the system discharge sewage to the ❑ Yes ® No rid surface? Does the system discharge sewage to drain 0 Yes El No tile or surface waters? Name: Frank Bakke Does the system cause sewage backup ❑ Yes ►. No into dwelling or establishment? Do other situations exist that have the potential to immediately and adversely impact or threaten public health or safety (electrical, unsafe covers, etc.)? Any "yes" answer indicates that the system is an imminent threat to public health and safety. FAX NO. : 6514550483 Mar. 31 2010 03:49PM P3 ❑ Yes El No ® Yes ❑ No Does the system pose a threat to ground water for any conditions deemed non - protective as determined by the inspector? "Yes" indicates that the system is failing to protect ground water. If "yes", describe the condition noted: dry well Verification Method ": (Optional) (Check the appropriate box) Searched for surface outlet ❑ Performed hydraulic test 10 Searched for seeping in yard ❑ Checked for backup in home ❑ Excessive ponding in soil system/D -boxes ® Homeowner testimony ❑ Examined for surging in tank ❑ "Black soil" above soil dispersal system ❑ System requires "emergency" pumping Q Perforated dye test © Other "No standard protocol exists This list is not exhaustive, in sequential artier, 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 contusions must be completed by an inspector. Completed form must be submitted to the local unit of government within 15 days. Property owner name(s): Estate of William J. Swart Property address: 1580 Letendre St. Eapan, MN 55121 Property owner's address (if different): County: Dakota Phone: 651-403-1645 1 hereby certify that 1 personaly made the observations, irtvpretations, and conclusions reported on this form and that they are correct. Certification number. C4209 Business license name and number Mendota Environmental L1718 or Name of local unit of ovemment: Signature: J�.., ._-_ Date: "V 31 10 FROM : Parcel number: 104490012102 Tank Integrity and Safety Compliance Compliance Issue #2 of 4 Date of observation; 3/31/10 Reason for observation: property transfer This form expires on (three years): 3131/13 Compliance questions/criteria: (Required) (Check the appropriate box) Does the system consist of a seepage pit`, cesspooi, drywell, or leaching pit? Do any sewage tank(s) leak below their designed operating depth? If yes, identify which sewage see site sketch tank leaks. Any 's" answer indicates that the system is failing to protect ground water. * Seepage pits meeting 70802550 may be compliant if allowed in ordinance by local permitting authority. Safety Check 1. Are any maintenance hole covers damaged, cracked, or appeared to be structurally unsound? 2. Were all maintenance hole covers replaced in a secured manner (e.g., all screws replaced)? 3. Was secondary access restraint present (safety pan, second cover, or safety netting) — highly recommended. 4. Was any other safety/health issue present? 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); Estate of William J. Swart Property address: 1580 Letendre St. Eagan, MN 55121 Property owner's address (if different): County: Dakota Phone: 651-403 -1645 1 hereby certify that 1 personalty made the observations, interpretations, and conclusions reported on this form and that they are aoneat Name: Frank Bakke Business license name and number Mendota Environmental L1718 or Name of local unit of government: Signature: _ FAX NO. : 6514550483 Mar. 31 2010 03:49PM P4 N Yes 0 N ❑ Yes ❑ No System status: ❑ Compliant ® Noncompliant (as determined by this form) Verification Method"*: (optional) (Check the appropriate box) • Probed tank bottom ❑ Observed low liquid level ❑ Examined construction records ❑ Examined empty (pumped) tank ❑ Probed outside tank for "black soil" ❑ Pressure/vacuum check ❑ Other: " 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 number. C4209 Date: 7/11 Q ❑ Yes* rar No ® Yes ❑ No* ❑ Yes N No ❑ Yes* ® No Post -ite Fax Note 7671 bat' l % /, „I I. tit ( 7 I To i j . L E•410/.,..- � �ot From { , / # t_ J'wt 1.'v`-k' cc.... Pnon®# / Phone # L. ( z. - Lit ( G c rI Fax # eJ i - ;1- . -6q q Fax # FPOM : FAX NO. : 6514550483 Mar. 31 2010 03:48PM P1 d1\ j \i