Compliance Inspection Compliance Inspection Compliance Inspection # CI-2022-3411, Submission # Submission-2022-3208, UID # 39096
Status: Compliance Inspection Accepted
 

System Status

System status on date: 11/04/2021 System Status: Compliant

Property Information

Property Information:
Compliance StatusProperty RecordProperty AddressProperty OwnerProperty Attributes
Compliance ExpirationCompliance StatusParent GeoCodePINSite AddressBuilding NumberStreet NameTypeDirCityMunicipalityzipOwnerLotBlockPlat Year BuiltProperty Hold
100322114000622840 IMPERIAL AVE N, CITY OF FOREST LAKE22840IMPERIALAVENFOREST LAKECITY OF FOREST LAKE55025IBRAHIM AHMAD & TAMER91CAMERON HIGHLANDS2001No
Property Owner's Mailing Address
(if different than property address):
22840 Imperial Ave. N
Forest Lake MN 55025
Owner's representative:
Name:
Jackie Pau;
Phone:
(763464 - 3249
Email:
noemail@noemail.com

Impact on Public Health

System discharges sewage to
the ground surface:
No System discharges sewage to
drain tile or surface waters:
No System causes sewage backup
into dwelling or establishment:
Yes
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
System is non protective of groundwater for other
conditions as determined by the inspector:
No
Explain:
Two manhole covers were us safe. The manhole covers were replaced 11-9-2021

Date of Install

Date of install known: Yes
Date of installation: 10/18/2021

Soil Separation

Shoreland/Wellhead Protection/Food, beverage, lodging? Yes
Drainfield has at least a three-foot vertical separation
distance from periodically saturated soil or bedrock.:
Yes
Drainfield meets the designed vertical separation
distance from periodically saturated soil or bedrock.:
Yes
Verification method(s):
Conducted soil observation(s) (Attach boring logs)
Comments/Explanation:
See report
A. Bottom of distribution media: 20 Decimal Feet
B. Periodically saturated soil/bedrock: 16 Decimal Feet
C. System separation: 36 Decimal Feet
D. Required compliance separation: 36 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

Certification

Inspector:
NameLicense NumberPhone NumberAddressMaintainerInstallerService ProviderDesignerInspector
AT Septic Inspection & Design IncL3886320-980-023549861 Government Rd Rush City, MN 55069YesYesYesYesYes
Please search for and choose SELF/OTHER if what you need does not appear in the list
Inspector Email Address: noemail@noemail.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 #7748 (02/11/2022)

Charge Cost Quantity Total
Non-Taxable
added 02/11/2022 3:26 PM

$47 Flat Fee

$44.00 x 1 $44.00
Grand Total
Total $44.00
Payment 02/22/2022$44.00
Due$0.00
Action: Print  

Approvals

ApprovalSignatureOptions
ApplicantAmy Thompson - 12/23/2022 2:16 PM - witnessed by Sarah Borrell
5c4cdfac30f9f175ccca46e2ac38feb5
ad91435153377e5831a8cd5b7bd4f1f8
 
#1 Compliance Inspection AcceptedSarah Borrell - 12/23/2022 2:16 PM
4bb6409547d287252247c3b6fd8095f3
98775671dd200af1474571fda8465640
 
Inspection has been approved. All signatures have been obtained.
Text:
File(s):
    Text:
    Invoiced 02-11-22-DL
    Called Amy 2/17/22 about invoice and she said she would get it mailed out today.
    
    3/3/22 (SB) spoke with Inspector.  Roots in tank enter at sidewall & lid and are hanging into tank; confirmed per report tank does not leak below OL. There are typos in Section 5, dipline is -16" + 20" of good soil. She intended to send an amended page. Discussed requirement of Operating Permit w/ SSTS team and determined an operating permit would not be required.
    File(s):
    Compliance Letter Type: Certificate of Compliance Who's signature should be on the letter? Sarah Borrell Permit number to reference in "No Replace" letter:
    Was the letter sent? Yes Compliant/Non-Compliant: Compliant
    Certificate of Compliance:
      Letter of Non-Compliance:
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