SSTS Permitting

Compliance Inspection Compliance Inspection Compliance Inspection # CI-2020-2048, Submission # Submission-2020-2141, UID # 26382
Status: System Replaced

System Status

System status on date:

01/08/2020

System Status:

Noncompliant

System - Noncompliant

Reason(s) for noncompliance:

Impact on Public Health (Compliance Component #1) - Imminent threat to public health and safety

Soil Separation (Compliance Component #4) - Failing to protect groundwater

Property Information

Property Information:

Compliance Status		Property Record		Property Address								Property Owner	Property Attributes
Compliance Expiration	Compliance Status	Parent GeoCode	PIN	Site Address	Building Number	Street Name	Type	Dir	City	Municipality	zip	Owner	Lot	Block	Plat	Year Built	Property Hold
			3503221420008	18400 IVYWOOD AVE N, CITY OF FOREST LAKE	18400	IVYWOOD	AVE	N	FOREST LAKE	CITY OF FOREST LAKE	55025	LUNDSTROM BJORN				1975

Owner's representative:

Name:

Linda Hacker

Phone:

(123

) 456

- 7890

Email:

noemail@email.com

Impact on Public Health

System discharges sewage to the ground surface:	Yes	System discharges sewage to drain tile or surface waters:	No	System causes sewage backup into dwelling or establishment:	No
Verification method(s):	Other methods not listed (See Comments/Explanation)	Comments/Explanation:	See Report

Tank Integrity

System consists of seepage pit, cesspool, drywell, or leaching pit:	No
Sewage tank(s) leak below their designed operating depth:	No
Verification method(s):	Other methods not listed (See Comments/Explanation)
Comments/Explanation:	See Report

Other Compliance Conditions

Maintenance hole covers are damaged, cracked, unsecured, or appear to be structurally unsound:	No
Other issues (electrical hazards, etc.) to immediately and adversely impact public health or safety:	No
Explain:	See Report
System is non protective of groundwater for other conditions as determined by the inspector:	No
Explain:	See Report

Date of Install

Date of install known:

Soil Separation

Shoreland/Wellhead Protection/Food, beverage, lodging?	No
Drainfield has at least a three-foot vertical separation distance from periodically saturated soil or bedrock.:	No
Drainfield meets the designed vertical separation distance from periodically saturated soil or bedrock.:	No
Verification method(s):	Conducted soil observation(s) (Attach boring logs) Other (See Comments/Explanation)
Comments/Explanation:	See Report
A. Bottom of distribution media:	0 Decimal Feet
B. Periodically saturated soil/bedrock:	0 Decimal Feet
C. System separation:	0 Decimal Feet
D. Required compliance separation:	0 Decimal Feet

Operating Permit and Nitrogen BMP

Is system operating under an Operating Permit:	No
Is the system required to employ Nitrogen BMP:	No

Comments and File Attachments

Comments or recommendations:	See Report
Attach Files:	File 1: 18400_Ivywood_Ave_N.pdf

Certification

Inspector:

Name	License Number	Phone Number	Address	Maintainer	Installer	Service Provider	Designer	Inspector
Midwest Sewer Services	L2896	651-492-7550	6616 Indian Wells Trail Grant, MN 55110	Yes	Yes	Yes	Yes	Yes

Please search for and choose SELF/OTHER if what you need does not appear in the list

Inspector Email Address:

brian@midwestsoiltesting.com

Terms

Certification

By submitting this form I hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No determination of the 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

Invoice #5149 (01/10/2020)

Charge	Cost	Quantity	Total
Non-Taxable
Compliance Inspection Fee added 01/10/2020 10:22 AM $41 Flat Fee	$41.00	x 1	$41.00
Subtotal			$41.00 0
Grand Total
Total			$41.00
Payment 01/20/2020			$41.00
Due			$0.00

Action: Print

Approvals

Approval	Signature	Options
Applicant	Brian Humpal - 01/10/2020 10:22 AM e34d9ad2638cfc61a078a71c9e6051cb e13b0cd4e1c894294c965632db4312a9
#1 Compliance Inspection Accepted	Tyler Dale - 01/22/2020 3:03 PM 12616952d1160bac63abc13c921e5251 48f698057f016ff386ba1c96c1c447bd

Inspection has been approved. All signatures have been obtained.

Public Notes

Text:
File(s):

Internal Notes

Text:
File(s):

Create Letter

Compliance Letter Type:	Imminent Threat, Abatement Notice and Order	Who's signature should be on the letter?	Tyler Dale	Permit number to reference in "No Replace" letter:
Was the letter sent?	Yes	Compliant/Non-Compliant:

Letter of Compliance

Certificate of Compliance:

Letter of Non-Compliance

Letter of Non-Compliance: