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Home My WebLink About2013-07-10 WC Dept of Health System Abandonment Permit & Related Documentation Washington Department of Public Health and Environment 14949 62nd Street North PO Box 6 Permit Fee: $117.00 ® Stillwater MN 55082-0006 Office:651-430-6655 TTY: 651-430-6246 Fax: 651-430-6730 Total Fee: $117.00 ^ Previous Payment $117.00 Community: Oak Park Heights Balance Due $0.00 Permit Number: 1700-13-1 Owner: MN Dot ' 53 P ,iik , -.- --,le, Applicant: Bursch Brothers Inc 7,2":„----------‘ cm() , PERMISSION IS HEREBY GRANTED To execute the work specified in this permit on the following identified property upon express condition that said persons and their agents, and employees shall conform in all respects to the provisions of Ordinance#128, Washington County Development Code, Chapter Four, Individual Sewage Treatment System Regulations. This permit may be revoked at any time upon violation of any of the provisions of said ordinance. Project Address: 5891 beach RD N Geo Code: 03-029-20-21-0027 Contractor: Bursch Brothers Inc Type of System: System Abandonment Authorized Work/Special Conditions 1. Abandon old tank(s) properly. • • N. Permit Issue Date: 7 10 2013 Christopher W:""LeCrair, REH ~ Permit Expiration Date: July 10,2014 Senior Environmental Specialist ` Department of Public Health ---»r� ��- -�� and Environment �� ^ - / Undividua8Sew�ge Treatment System Unspec%ion Form Project Address: 5891 beach RD N Application ID: 1700'13'1 Community: Oak Park Heights Geo Code: 03-029-20-21-0027 Owner: MN Dot Type uYSystemm: System Abandonment Applicant: Bursch Brothers Inc Designer: Bursch Brothers Inc ' Type of Installation: [lNew Type of LI Site Review Inspector: Ej Pete Canzo| FlRopai/ Inspection: E] Tank 0ChrioLeC|air 0Rep|aoempnt 0Rough-Up DOther 0Other LI Treatment Area Inspection Dates: ^� � / L_/�� ' �� Fine{ � � Number of Bedrooms: �� ~ Installer: ��''�' rft �� /c��—�^ �- - --� _�,_�~'..-_ -�-_ .' _ � .'� Date: Conclusions: 0 Mound 0At-Gnado Absorption Area FlSoUBor�g 0-- -- Percent Slope Sand Below Bed [] Soil Pit Fl Site Unsuitable Depth of Pit/Boring LI Additional Tests Required Upslope Width Rock Below Pipe Comments Downslope Width PeriSize/Spauing Sideslope Width Pipe Size/Spacing Pressure Bed Dimensions: Length Width ., Tanks Information --~-�� ~ --~~ ~�~.~~�-~^~^�~^ '.�_ _,-,;: Tank 1 FlNew Baffle Type Flp�uho UMS�honCaPachy Feet of Head � LJE�n<ing �~ 1 LJFiberglass Horsepower/GPM Size of Discharge 1 Tank 2 El New ElSa»-T Gallons Per Cyde Line: �l Existing LJConu'ete Type/Location or Gallons Per Minute Alarm TrencheS Bred or Graveness °===�= .- .' Fl Drop Box 0 Distribution Box 0 Gravity El Pump Trench 0 Pressure Bed Building(s)to tanks Fl Serial Fl Parallel 0 Chambers 0Gnavo||e»u Fl O^ 0 10" Building(s)to drainfield Surface Water Trench T1 Trench T1 Trench Width Rock Below Depth (in) Length (ft) �� 24^ Pipe Property Lines T2 T2 �� 03G^ 0O^ Wells 0 50' 0 100' T3 T3 El Other 0 12' 0 18^ .� Px.ysurTest __��- ` T4 T4 Trench Spacing 0 24^ Time Time T5 T5 PSI PSI Pressure Bed Dimensions: Length Width Absorption Area ^ Comments r� � / -,- '�/ (.^�- !-� .' �,,�� /��/`-�c�l ,- 'Y \ ; . ! � i�� • . ` ` Inspector Government Center- 14949 62nd Stree North PO Box 6 Stillwater, Minnesota 55082-0006 Phone: 051-430-6655 Fax: 051-43046730 I I Y: 051-430'0240 www.co.washington.mn.us Equal Employment Opportunity/Affirmative Action Vt7as1iington 2013 SEPTIC PERMIT APPLICATION OUny�_ Washington County Department of Public Health Et Environment PERMIT NUMBER \J/ 14949-62nd St N, P.O. Box 6,Stillwater MN 55082-0006 651.430.6655 FAX: 651.430.6730 PROPERTY ft APPLICANT INFORMATION PROPERTY ADDRESS: j 144 8 i esct-t f (cc S 2 Pt. GEOCODE: p S ? y=, ',,-, 'V"' � t USE OF BUILDING: js SINGLE FAMILY HOME ❑ NON-SINGLE FAMILY APPLICATION TYPE: ❑ NEW ❑ REPLACEMENT APPLICANT� ADDRESS Q (S`y S5 PHONE NUMBER(S) NAME(S) l) b qs, yj CITY it l J ZIP -.3 3 L// jt la iL/93 OWNER(IF DIFFERENT FROM APPLICANT) ADDRESS PHONE NUMBER(S) NAME(S) CITY ZIP SYSTEM TYPE ❑ TYPE I SYSTEM(Trenches,Pressure Bed,Mound,At-Grade) ❑ TYPE II SYSTEM(Floodplain,Holding Tanks,Privy) ❑ TYPE III SYSTEM ❑ TYPE IV SYSTEM(System using Registered Products)* ❑ TYPE V SYSTEM ❑ MSTS(>5,000 GPD) ❑ LOT SPLIT ❑ DRAINFIELD ❑ PRESSURE BED ❑ MOUND ❑ AT-GRADE ❑ TANK REPLACEMENT ❑ SUBDIVISION REVIEW FEE SCHEDULE - 2012 ❑ SOIL/SITE REVIEW APPLICATION FEE' $285 *This fee does not apply to: Reissuance of Expired Permits,Tank Replacement, Lot APPLICATION FEE: Split or Subdivision Approval,or System Abandonment Permits ❑ PERMIT FEE- PRIVY OR HOLDING TANK $117 ❑ PERMIT FEE- DRAINFIELD OR PRESSURE BED $300 ❑ PERMIT FEE-MOUND OR AT-GRADE $480 `• '4\ ❑ PERMIT FEE-NON SINGLE FAMILY ❑ 1-500 GALLONS PER DAY $730 =P\1°) PERMIT FEE: ❑ 501-1000 GALLONS PER DAY $875 ❑ 1001-5000 GALLONS PER DAY - $1 100 ❑ 5001-999 GALLONS PER DAY ❑ 10,000 GALLONS PER DAY OR GREATER MPCA PERMIT REQUIRED ❑ PERMIT FEE- HOLDING TANK REPLACEMENT(NO SOIL TEST/SITE REVIEW) $117.. PERMIT FEE-SYSTEM ABANDONMENT $117 ❑ PERMIT FEE- REISSUANCE OF EXPIRED PERMIT 50%of permit fee(does not include initial soil/site review fee) Make Checks Payable to WASHINGTON COUNTY TOTAL PERMIT FEE=APPLICATION FEE+PERMIT FEE: 1 I 2 vr.v,.x'"a sr_roiw nnr >rrt . ❑ SUBDIVISION SOIL/SITE REVIEW-APPLICATION FEE $200+$85 PER LOT SUBDIVISION REVIEW BASE FEE: ❑ LOT SPLIT APPROVAL $200+$85 PER LOT + LOTS: X$85 PER LOT Make Checks Payable to WASHINGTON COUNTY TOTAL SUBDIVISION REVIEW OR LOT SPLIT APPROVAL FEE: The following exhibits are required as part of the application and shall be attached hereto:Percolation Test Reports;Soil Boring Logs;Site Plan drawn to scale showing location of buildings,lot lines, percolation test holes,soil boring holes,proposed location of system and location of well(s);one(1)copy of the System Design;and one(1)copy of the Final Building Plan. The house and drainfield areas must be staked. Inaccurate or incomplete information will result in delays in processing. AGREEMENT: The undersigned hereby makes Application for Permit to Install or Extend the Sewage Treatment System herein specified,agreeing that all work shall be done in strict accordance with ordinances and regulations of the County of Washington,Minnesota. Applicant agrees that the Site Plan,Sketches,and Design submitted herewith,and which are reviewed by Washington County, together with any requirements and/or restrictions made necessary by conditions peculiar to a particular location,shall become part of the permit. Applicant further agrees to provide access,at reasonable times,to Washington County for the purpose of performing inspections required and that no part of the system shall be covered until it has been inspected and accepted. APPLICATION IS FOR AN INSTALLATION AT A SPECIFIC LOCATION;ANY DEVIATION FROM THE APPROVED LOCATION WILL VOID THE PERMIT. It shall be the responsibility of the applicant for the permit to notify the Office of the Washington County Department of Public Health E Environment that the installation is ready for inspection. PERMITS WILL NOT BE ISSUED ONCE FROZEN GROUND CONDITIONS EXIST due to the inability to conduct soil reviews unless arrangements are made BY THE APPLICANT to provide a backhoe,geo- probe,or any other device that can penetrate the frozen soil to allow Washington County to conduct a soil review. In accordance with Minnesota Statute 15.99,Subdivision 2,Washington County has up to SIXTY(60)DAYS to review and approve or deny the permit application. I hereby certify the above to be true and correct. I hereby give the Washington County Department of Public Health Et Environment permission to enter upon my property during normal business hours for the purpose of determining the suitability of the location,design,and construction,which may include minor excavations or soil borings by the Department. , n Signature of Applicant(Owner or Contractor) Date An Equal Opportunity/Affirmative Action Employer If You Need Assistance Due to Disability or Language Barrier,Please Call 651-430-6655(TTY 651-430-6246) .. \\7ashington Department of Public Health and Environment County 14949 62nd Street North Box 6 Stillwater MN 55082-0000 06 Office: 651-430-6655 TTY: 651-430-6246 Facsimile Machine: 651-430-6730 Receipt Number: 2284 Date: 7/11/2013 Check Number: 18132 Received For: Application #1700131 ii Application Type: System Abandonment i. Ili Property Address: 5891 beach RD N Community: Oak Park Heights Received From: Bursch Brothers Inc Hanover MN 55341 • I Description Permit Fee: $117.00 Total Fee: $117.00 - - i ili Amount Received: $117.00 II ; - - Previous Payments: $0.00 i I 11 Balance Due: $0.00 '" Issued By JLL Equal Employment Opportunity/Affirmative Action 07/23/2013 10:50 SDE - 6514306730 NO.783 t01 00 isig Minnesota Pollution SSTS Abandonment Control Agency 520 Lafayette Road North Reporting Form St.Paul,MN 55155-4194 Subsurface Sewage Treatment Systems (SSTS) Program) Instructions This form is offered to meet the abandonment requirements of Minn. R. 7080.2500 and Disclosure Requirements of Minn.Stat. §115.55,subs.6. Future water supply well placement can also be effected by an abandoned SSTS. The use of this form is not mandatory;however the information on this form must be submitted to the local government unit(LGU) within 90 days after the abandonment.This form may be completed by a certified SSTS practitioner or by an individual who has direct knowledge of how the system was abandoned. Property Information Date of abandonment: °1 Ito 112 Reason for abandonment: �V' 1 _�Q Sec- • _. ,____... 5._._ _.. Property owner name(s): YP1..t dr+ ---.---- -----••- Property owner's address: 4,032 P ►l& AJE — — --- City - State: ^ ---..... Zip: _._...._ Site address(if different): ••. -- --�° City: _! Stale: — _,.. Zip: Compliance Information 1. NI solids and liquids removed from all tanks? xi Yes .0 No Disposal Slte: Ala. 1 ALE --kcwit'w 2. All electrical devices and devices containing mercury removed? ❑Yes ❑ No Disposal Site: 3, All underground sewage tanks crushed and filled with soil or rock material? ❑Yes ❑ No or Removed and disposed off site? , Yes ❑ No Disposal Site: 3uwk _`�+•,_T".e. 1.-4‘spirtA 4. Contaminated materials'removed and disposed off site? ❑Yes ❑ No Disposal Site: J 5. All underground cavities"crushed end filled with soil or rock material? ;$l Yes ❑ No or: Removed and disposed off site? ❑Yes ❑No Disposal Site: 6. Future discharge to system permanently denied? EYes ❑ No Method(s)used: Alt oininw —�_._... __r—_.. ...—.... 'Contaminated materials• Distribution media,soli 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,08 2500 leaching 1 pits, Doesn�include chamber media,privies, boxes,s. o distribution chambers boxes. 07/23/2013 10:50 SDE 4 6514306730 NO.783 D02 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 W I Loo.tZ A° w PE Iii ii-vE °- ,- lob p -ntak QL\E �. _.Q ‘11)of ■ Certification !hereby certify the system was abandoned in accordance with Minn. R. 7080.2500 and any local requirements. Name(please print): Tear I Title: ,_y _ P�cs�cl•. Address: 9C,. o s 5C City: UaiD►te+ State: h'1 I Zip: 55 3 14/ Phone: to t2— 22-1— 3 License#if appl' a): L 24 24• Date: //245/13 _ Signature: - --- • '07/23/2013 10:50 SDE - 6514306730 NO.783 D03 Minnesota Pollution SSTS Abandonment Control Agency 520 Lafayette Road North Reporting Form St.Paul,MN SSISS-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 AO ha Reason for abandonment iPCr• -- , Property owner name(s): rh.J ck+ —�- Property owner's address: ,5 A9 City: State: fr141 Zip. Site address (if different): SAme State: Zip. ._ City: S _ _ .... -._... Compliance Information 1. All solids and liquids removed from all tanks? Yes ❑ No Disposal Site: _$i 8 422Id CSC 41 t 2. All electrical devices and devices containing mercury removed? ❑Yes [] No Disposal Site: 4u*.4 - -- 3. All underground sewage tanks crushed and filled with soil or rock material? ❑Yes 0 No or Removed and disposed off site? N'Yes ❑No Disposal Site: -Ati..vs.. vc le A ... —-. . 4. Contaminated materials*removed and disposed off site? ❑Yes ❑ No Disposal Site: P c .%E - ------ 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: Alt (AO Ex4.•daj, Ail I Accttcant_ *Contaminated materials■ Distribution media, soil or sand within three feet of the system bottom, distribution pipes, geotextile fabric/rosin paperlstraw, tanks, contaminated soil around leaking tanks, any soil that received sewage from a surface failure(7080.2500 subp.3). "Underground cavities• Cesspools, teaching p � privies, pump chamberS subp ) Does not chamber media, dropbes, or distribution boxes. 07/23/2013 10:50 SDE -' 6514306730 NO.783 ®04 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 i I ipC�[ t ilaJA t-i000 GkittxS -kJ L 5841 BAD, Etkl Certification I hereby certify the system was abandoned In accordance with Minn. R. 7080.2500 and any local requirements. Name(please print): —re -r•c l `"ws._1i.. Title: \tug {pyy-?I cik Address: CO gbh City: WAnDJw State: VI'I+./ — Zip: 74i Phone: (8(7 22 1-1443 License#if applicable): LZq Date: x1174 Iii Signature: 07/23/2013 10:50 SDE 4 6514306730 NO.783 P05 • • Ende Septic Service, LLC 24910 Territorial Road • Rogers, MN 55374 Phone: 763-428-4489 '�- info @endeseptic.com LCP w INVOICE DATE 1,, fib- a NAME S3yyrc,1-N5 - --- _ ADDRESS CITY STATE ZIP 1)OV QUAN. DES ._ AMOUNT I _ 1 V I = ►r _.... . rifl Sao.. a}' gocil • L . 'Na ' se -5 - - ---, • Y O . KEEP CO OUR RECORDS