Compliance Inspection Form Existing Subsurface Sewage Treatment Systems (SSTS)

Transcription

1 Compliance Inspection Fm Existing Subsurface Sewage Treatment Systems (SSTS) Doc Type: Compliance and Enfcement Instructions on page 6 Summary Fm (Completed fm must be submitted to the local unit of government within 15 days.) Parcel number: System status: Compliant ncompliant (based on all compliance requirements) F Local Tracking Purposes: Property Infmation Property owner address (if different): Date system constructed: Permitting authity: Reason f inspection: System Description Brief system description: Local permit number: Number of bedrooms: Design flow rate: Is the system: In Sheland area? An U.S. Environmental Protection Agency (EPA) Class V Injection Well? In Wellhead Protection Area? System serving a Minnesota Department of Heath (MDH) licensed facility? Compliance Status (Based on state requirements additional local requirements may also apply.) Based on the infmation gathered and repted on attached fms, the compliance status of this system is (check one): Certificate of Compliance valid until (3 years from date of rept): tice of ncompliance - F ncompliant systems: The reason f noncompliance is: This noncompliant system is classified as (check one below): Imminent threat to public health & safety Failing to protect ground water t in compliance with operating permit I hereby certify that all the necessary infmation has been gathered to determine the compliance status of this system. determination of future system perfmance has been n can be made due to unknown conditions during system construction, possible abuse of the system, inadequate maintenance, future water usage. Required Attachments Hydraulic Perfmance Tank Integrity Operating Permit Fm (if applicable) Soil Bing Logs Soil Separation System drawing/as-built drawing Any local requirements that are different from what is required on this fm Other infmation (list): Upgrade Requirements (derived from Minn. Stat ) An imminent threat to public health and safety (ITPHS) must be upgraded, replaced, its use discontinued within ten months of receipt of this notice within a shter period if required by local dinance. If the system is failing to protect ground water, the system must be upgraded, replaced, its use discontinued within the time required by local dinance. 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, its use discontinued, notwithstanding any local dinance that is me strict. This provision does not apply to systems in sheland areas, Wellhead Protection Areas, those used in connection with food, beverage, and lodging establishments as defined in law. wq-wwists4-31 4/24/09 Page 1 of 8

2 Parcel number: System status: Compliant ncompliant (as determined by this fm) Hydraulic Perfmance and Other Compliance Compliance Inspection Fm f Existing SSTS Compliance Issue #1 of 4 Date of observation: Reason f observation: This fm expires upon next inspection in three years, whichever occurs first: Compliance questions/criteria: (Required) Does the system discharge sewage to the ground surface? Does the system discharge sewage to drain tile surface waters? Does the system cause sewage backup into dwelling establishment? Do other situations exist that have the potential to immediately and adversely impact threaten public health safety (electrical, unsafe covers, etc.)? Any yes answer indicates that the system is an imminent threat to public health and safety. Does the system pose a threat to ground water f any conditions deemed nonprotective as determined by the inspect? indicates that the system is failing to protect ground water. If yes, describe the condition noted: Verification Method*: (Optional) Searched f surface outlet Perfmed hydraulic test Searched f seeping in yard Checked f backup in home Excessive ponding in soil system/d-boxes Homeowner testimony Examined f surging in tank Black soil above soil dispersal system System requires emergency pumping Perfmed dye test Other: * standard protocol exists. This list is not exhaustive, in sequential der, n does it indicate which combinations are necessary to make this determination. This fm is to be completed and attached to the Summary Fm of the Minnesota Pollution Control Agency s (MPCA) Compliance Inspection Fm f Existing Subsurface Sewage Treatment Systems. Observations, interpretations, and conclusions must be completed by an inspect. Completed fm must be submitted to the local unit of government within 15 days. Property owner s address (if different): I hereby certify that I personally made the observations, interpretations, and conclusions repted on this fm and that they are crect. wq-wwists4-31 4/24/09 Page 2 of 8

3 Parcel number: System status: Compliant ncompliant (as determined by this fm) Tank Integrity and Safety Compliance Compliance Inspection Fm f Existing SSTS Compliance Issue #2 of 4 Date of observation: This fm expires on (three years): Reason f observation: Compliance questions/criteria: (Required) Does the system consist of a seepage pit*, cesspool, drywell, leaching pit? Do any sewage tank(s) leak below their designed operating depth? If yes, identify which sewage tank leaks. Any yes answer indicates that the system is failing to protect ground water. * Seepage pits meeting may be compliant if allowed in dinance by local permitting authity. Safety Check Verification Method**: (Optional) Probed tank bottom Observed low liquid level Examined construction recds Examined empty (pumped) tank Probed outside tank f black soil Pressure/vacuum check Other: ** standard protocol exists. This list is not exhaustive, in sequential der, n does it indicate which combinations are necessary to make this determination. 1. Are maintenance hole covers damaged, cracked, appeared to be structurally unsound? * 2. Were maintenance hole covers replaced in a secured manner (e.g., screws replaced)? * 3. Was secondary access restraint present (safety pan, second cover, safety netting) highly recommended. 4. Are other safety/health issue present? * Explain: *System is an imminent threat to public health and safety. This fm is to be completed and attached to the Summary Fm of the Minnesota Pollution Control Agency s (MPCA) Compliance Inspection Fm f Existing Subsurface Sewage Treatment Systems. Observations, interpretations, and conclusions must be completed by an inspect, maintainer, service provider. Completed fm must be submitted to the local unit of government within 15 days. Property owner s address (if different): I hereby certify that I personally made the observations, interpretations, and conclusions repted on this fm and that they are crect. wq-wwists4-31 4/24/09 Page 3 of 8

4 Parcel number: System status: Compliant ncompliant (as determined by this fm) Soil Separation Compliance and Other Compliance Compliance Inspection Fm f Existing SSTS Compliance Issue #3 of 4 Date of observation: This infmation on this fm does not expire. Reason f observation: Compliance questions/criteria: (Required) F systems built pri to April 1, 1996, and not located in Sheland Wellhead Protection Area not serving a food, beverage lodging establishment: Does the system have at least a two-foot vertical separation distance from periodically saturated soil bedrock? F non-perfmance systems built April 1, 1996, later f non-perfmance systems located in Sheland Wellhead Protection Areas serving a food, beverage lodging establishment: Does the system have a three-foot vertical separation distance from periodically saturated soil bedrock?* F reduced separation distance systems (i.e., perfmance systems under old Type IV V system under new ): Does the system meet the designed vertical separation distance from periodically saturated soil bedrock?* Any no answer indicates that the system is failing to protect ground water. Verification Method**: (Optional) Conducted soil observation(s) (attach bing logs) Two previous verifications (attach bing logs) Other: Soil observation does not expire. Previous observations by two independent parties are sufficient, unless site conditions have been altered. * May be reduced by up to 15 percent if allowed in local dinance. ** standard protocol exists. This list is not exhaustive, in sequential der, n does it indicate which combinations are necessary to make this determination. This fm is to be completed and attached to the Summary Fm of the Minnesota Pollution Control Agency s (MPCA) Compliance Inspection Fm f Existing Subsurface Sewage Treatment Systems. Observations, interpretations, and conclusions must be completed by an inspect designer. Completed fm must be submitted to the local unit of government within 15 days. Property owner s address (if different): I hereby certify that I personally made the observations, interpretations, and conclusions repted on this fm and that they are crect. wq-wwists4-31 4/24/09 Page 4 of 8

5 Parcel number: System status: Compliant ncompliant (as determined by this fm) Operating Permit Compliance and Nitrogen BMP Compliance Compliance Inspection Fm f Existing SSTS Compliance Issue #4 of 4 Applicability: Is the system operated under an Operating Permit? If yes, then complete item A, below Is the system required to employ a nitrogen BMP? If yes, then complete item B, below If the answer to both questions is no, then this fm does not need to be completed. Compliance questions/criteria: (Required) A. F systems with operating permits: Has all the required moniting and maintenance taken place and does the moniting indicate compliance with the permit thresholds? B. F a system that has a required nitrogen reducing BMP and does not have an operating permit: Is the nitrogen BMP in-place and appears to be properly operating? Any no answers indicates noncompliance Date of observation: Operating permit number: Reason f observation: This fm expires upon next inspection in three years, whichever occurs first: This fm is to be completed and attached to the Summary Fm of the Minnesota Pollution Control Agency s (MPCA) Compliance Inspection Fm f Existing Subsurface Sewage Treatment Systems. Observations, interpretations and conclusions must be completed by an advanced inspect, service provider, maintainer (maintainer f holding tanks only). Completed fm must be submitted to the local unit of government within 15 days. Property owner s address (if different): I hereby certify that I personally made the observations, interpretations and conclusions repted on this fm and that they are crect. wq-wwists4-31 4/24/09 Page 5 of 8

6 Instructions Compliance Inspection Fm f Existing SSTS The Minnesota Pollution Control Agency s (MPCA) compliance inspection fm must be completed f all compliance inspections of existing Subsurface Sewage Treatment Systems (SSTS) (Minn. Stat subdivision 5a (i)). A compliance inspection is an inspection f the purpose of issuing a certificate of compliance notice of noncompliance (Minn. R. ch , subpart 18). Additional local fms may also be required in local dinance; if this is the case, attach the appropriate local fm(s) as well. The inspection fm is divided into five separate pages, each dealing with a separate compliance issue. The pages include: Summary Fm, Hydraulic Perfmance and Other Compliance Fm, Tank Integrity and Safety Fm, Soil Separation and Other Compliance Fm, and Operating Permit and Nitrogen BMP Compliance Fm. The following table indicates which sheets need to be completed f which type of systems: System Classification Summary Fm Hydraulic Perfmance and Other Compliance Fm Tank Integrity and Safety Fm Soil Separation and Other Compliance Fm Operating Permit and Nitrogen BMP Compliance Fm Type I and old Standard Systems x x x x Type II and old Alternative x x x x Systems Type III and old Other Systems x x x x Type IV x x x x x Type V and old Perfmance x x x x x Systems ISTS MSTS with nitrogen BMP x x x x x MSTS with advanced nitrogen reduction x x x x x ISTS = Individual Sewage Treatment Systems MSTS = Mid-Sized Subsurface Sewage Treatment Systems The purpose of multiple fms is to accommodate the different times the system may be assessed and the various individuals that may do the assessment. The goal of these fms is to document a continual state of compliance f the system. The final determination of compliance is determined on the Summary Sheet. This compliance status is based on the suppting compliance fms. Each suppting fm has an expiration date (except the Soil Separation fm), and, if not expired, will be used to suppt the Summary Sheet. 1. Summary Fm This is the fm that is completed once all the suppting infmation is gathered and the suppting fms are completed. This fm acts as the official tice of ncompliance Certificate of Compliance. The suppting fms must be attached to the summary fm. System Status (top line) - The Compliant ncompliant Section is based on all the required fms f that system. Property Owner Section - The Date System Construction query must be determined from recds owner testimony. If neither of these two sources are available, then a reasonable estimate should be made. The method used to determine the date (recds, estimate, testimony, etc could be provided near the date blank). System Description Section - The Local Permit Number, Number of Bedrooms and EPA Class V Injection Well queries are optional. An U.S. Environmental Protection Agency (EPA) Class V injection well is any system which serves me than one dwelling, receives non-domestic waste, a system which serves an Other Establishment which serves me than 20 persons per day. The Design Flow Rate must be determined estimated to determine if an advanced inspect is required to conduct the compliance inspection f that system. Wellhead Protection Areas can be found at: wq-wwists4-31 4/24/09 Page 6 of 8

7 Compliance Status Section - The compliance status required to be recded on this fm is based on state rule and state statute requirements. The compliance status is based on the suppting compliance fms. If local compliance requirements differ, that can be noted on a separate document, but the state fm still needs to be completed based on state criteria. Section - The final determination of compliance must be done by an inspect ( advanced inspect f a Type IV, Type V, system with a design flow of greater than 2,500 gallons per day). Required Attachments Section - The number of suppting compliance fms must be noted to ensure that the suppting infmation is complete. If you are filling the fm out on your computer, click the Print Preview button at this point this will trigger the automatic filling of system identification and Inspect infmation on subsequent pages. 2. Hydraulic Perfmance and Other Compliance Fm (Compliance Issue #1) This fm denotes compliance f surfacing of sewage if an inspect is determining that the system is failing to protect ground water other than a leaking sewage tank (septic, pump, cesspool, seepage pit, etc ) System Status (top line) - The Compliant ncompliant Section is based only on the criteria evaluated on this fm, not based on criteria on other fms. Compliance Questions/Criteria Section - The question in the lowest left-hand box which states: Does the system pose a threat to ground water f any condition deemed to be non-protective as determined by the inspect? is meant to allow the inspect to make a determination outside of the obvious non-protective systems (separation distance, leaky sewage tanks, etc ). These systems could include such things as a system covered by an impermeable surface. 3. Tank Integrity and Safety Compliance Fm (Compliance Issue #2) This fm denotes compliance f watertight tanks. Water tightness only refers to water tightness below the tank s designed operating depth. n-water tightness above the designed operating depth (i.e., water leaking into the tank) may be harmful f system operation, but is likely not a direct threat to environmental protection. System Status (top line) - The Compliant ncompliant Section is based only on the criteria evaluated on this fm, not based on criteria on other fms. 4. Soil Separation Compliance and Other Compliance Fm (Compliance Issue #3) This fm denotes compliance f the required vertical separation distance to the periodically saturated soil bedrock. System Status (top line) - The Compliant ncompliant Section is based only on the criteria evaluated on this fm, not based on criteria on other fms. Compliance Questions/Criteria Section - The 15 percent reduction in separation distance is further explained by the following table: System Type F systems built pri to April 1, 1996, and not located in Sheland Wellhead Protection Area not serving a Food, Beverage Lodging Establishment F non-perfmance systems built April 1, 1996, later f non-perfmance systems located in Sheland Wellhead Protection Areas Serving a Food, Beverage Lodging Establishment F reduced separation distance systems (i.e., perfmance systems under old Type IV V system under new ) Example Septic tank with trench system, built in 1980 not near a lake stream Septic tank with a trench system, built in 1980 within a Minnesota Department of Natural Resources (DNR) Sheland Area, Or Septic tank with trench system, built in 2001, not in a DNR Sheland Area Septic tank with advanced treatment to a trench system Required Separation Distance 24 inches Required Separation Distance with 15% Reduction 24 inches (15% rule does not apply) 36 inches 31 inches 12, inches 10, 21, 31 inches wq-wwists4-31 4/24/09 Page 7 of 8

8 Verification Method Section - The vertical separation distance must be determined. This determination can be made by the following: A. A new soil bing (which does not need to be verified by another f an existing system compliance inspection). B. Previous bings by two independent certified individuals (one can be the iginal bings by the designer). C. F me complex difficult site conditions, please refer to MPCA s fact sheet on determining vertical separation distance f existing systems. The soil bing(s) must be attached to this fm. 5. Operating Permit Compliance and Nitrogen BMP Compliance Fm (Compliance Issue #4) This fm denotes compliance f proper system operation as determined by compliance with the system s operating permit, f systems which employ a best management practice f nitrogen, whether that practice is currently in-place and property operating. These two conditions will only apply to a few systems which are required to have these measures, which began between the years 2008 and System Status (top line) - The Compliant ncompliant Section is based only on the criteria evaluated on this fm, not based on criteria on other fms. Compliance Questions/Criteria Section - The assessment of the nitrogen best management practice (BMP) can be a simple visual evaluation if the BMP is still present and whether it appears to be properly functioning at the time of inspection. wq-wwists4-31 4/24/09 Page 8 of 8