Ensuring the safety and compliance of subsurface sewage treatment systems (SSTS) is crucial for protecting public health and the environment. The Minnesota Pollution Control Agency (MPCA) Compliance Inspection Form serves as a comprehensive tool for evaluating the condition and compliance of existing SSTS. This form outlines specific criteria, including system status, reasons for noncompliance, and impact on public health across various compliance components. It is mandatory for inspectors to submit this detailed form to the Local Unit of Government (LUG) and the system owner within 15 days of inspection. The form not only assesses aspects like tank integrity, soil separation, and operating permit requirements but also provides a platform for inspectors to issue either a Certificate of Compliance, valid for three years, or a Notice of Noncompliance, complete with upgrade requirements. Additional local requirements might also apply, underscoring the form's role in adhering to both state and local regulatory standards. With sections dedicated to property information, system description, and necessary attachments, this document ensures a thorough inspection process, guiding inspectors through each step to accurately determine the system's compliance status.
| Question | Answer |
|---|---|
| Form Name | Mpca Compliance Inspection Form |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | pca, 2008, mn wq inspection form, wwists4 |
Compliance Inspection Form
Existing Subsurface Sewage Treatment Systems (SSTS)
Doc Type: Compliance and Enforcement
Inspection results based on Minnesota Pollution Control Agency (MPCA) requirements and attached forms – additional local requirements may also apply.
Submit completed form to Local Unit of Government (LUG) and system owner within 15 days
For local tracking purposes:
System Status
System status on date (mm/dd/yyyy):
Compliant – Certificate of Compliance
(Valid for 3 years from report date, unless shorter time frame outlined in Local Ordinance.)
Noncompliant – Notice of Noncompliance
(See Upgrade Requirements on page 3.)
Reason(s) for noncompliance (check all applicable)
Impact on Public Health (Compliance Component #1) – Imminent threat to public health and safety Other Compliance Conditions (Compliance Component #3) – Imminent threat to public health and safety Tank Integrity (Compliance Component #2) – Failing to protect groundwater
Other Compliance Conditions (Compliance Component #3) – Failing to protect groundwater Soil Separation (Compliance Component #4) – Failing to protect groundwater
Operating permit/monitoring plan requirements (Compliance Component #5) – Noncompliant
Property Information |
Parcel ID# or Sec/Twp/Range: |
|
|||||||||
Property address: |
|
|
Reason for inspection: |
|
|||||||
Property owner: |
|
|
Owner’s phone: |
|
|||||||
or |
|
|
|
|
|
|
|||||
Owner’s representative: |
|
|
Representative phone: |
|
|||||||
Local regulatory authority: |
|
|
Regulatory authority phone: |
|
|||||||
Brief system description: |
|
|
|
|
|
|
|
||||
Comments or recommendations: |
|
|
|
|
|
|
|||||
Certification
I 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.
Inspector name: |
|
Certification number: |
|
Business name: |
|
License number: |
|
Inspector signature: |
|
Phone number: |
|
Necessary or Locally Required Attachments
Soil boring logs |
Other information (list):
Forms per local ordinance
www.pca.state.mn.us • |
• |
TTY |
||
|
|
|
Page 1 of 3 |
Property address: |
|
Inspector initials/Date: |
| |
|
|
|
(mm/dd/yyyy) |
1. Impact on Public Health – Compliance component #1 of 5
Compliance criteria:
System discharges sewage to the |
Yes |
No |
ground surface. |
|
|
System discharges sewage to drain |
Yes |
No |
tile or surface waters. |
|
|
System causes sewage backup into |
Yes |
No |
dwelling or establishment. |
|
|
|
|
|
Any “yes” answer above indicates the system is an imminent threat to public health and safety.
Comments/Explanation:
Verification method(s):
Searched for surface outlet
Searched for seeping in yard/backup in home Excessive ponding in soil
“Black soil” above soil dispersal system
System requires “emergency” pumping
Performed dye test
Unable to verify (See Comments/Explanation)
Other methods not listed (See Comments/Explanation)
2.Tank Integrity – Compliance component #2 of 5
Compliance criteria:
System consists of a seepage pit, |
Yes |
No |
cesspool, drywell, or leaching pit. |
|
|
Seepage pits meeting 7080.2550 may be |
|
|
compliant if allowed in local ordinance. |
|
|
Sewage tank(s) leak below their |
Yes |
No |
designed operating depth. |
|
|
If yes, which sewage tank(s) leaks: |
|
|
|
|
|
Any “yes” answer above indicates the system is failing to protect groundwater.
Comments/Explanation:
Verification method(s):
Probed tank(s) bottom
Examined construction records
Examined Tank Integrity Form (Attach)
Observed liquid level below operating depth
Examined empty (pumped) tanks(s)
Probed outside tank(s) for “black soil”
Unable to verify (See Comments/Explanation)
Other methods not listed (See Comments/Explanation)
3. Other Compliance Conditions – Compliance component #3 of 5
a.Maintenance hole covers are damaged, cracked, unsecured, or appear to be structurally unsound.
b. Other issues (electrical hazards, etc.) to immediately and adversely impact public health or safety.
*System is an imminent threat to public health and safety.
Explain:
c. System is |
Yes* |
*System is failing to protect groundwater.
Explain:
Yes*
Yes*
No
No Unknown
No Unknown
www.pca.state.mn.us • |
• |
TTY |
||
|
|
|
Page 2 of 3 |
Property address: |
|
Inspector initials/Date: |
| |
|
|
|
(mm/dd/yyyy) |
4. Soil Separation – Compliance component #4 of 5
Date of installation: |
Unknown |
|||
|
(mm/dd/yyyy) |
|
|
|
Shoreland/Wellhead protection/Food beverage |
Yes |
No |
||
lodging? |
||||
|
|
|||
Compliance criteria: |
|
|
||
For systems built prior to April 1, 1996, and |
Yes |
No |
||
not located in Shoreland or Wellhead |
|
|
||
Protection Area or not serving a food, |
|
|
||
beverage or lodging establishment: |
|
|
||
Drainfield has at least a |
|
|
||
separation distance from periodically |
|
|
||
saturated soil or bedrock. |
|
|
||
Yes |
No |
|||
1996, or later or for |
|
|
||
systems located in Shoreland or Wellhead |
|
|
||
Protection Areas or serving a food, |
|
|
||
beverage, or lodging establishment: |
|
|
||
Drainfield has a |
|
|
||
separation distance from periodically |
|
|
||
saturated soil or bedrock.* |
|
|
||
|
|
|
||
“Experimental”, “Other”, or “Performance” |
Yes |
No |
||
systems built under |
|
|
||
or V systems built under 2008 Rules (7080. |
|
|
||
2350 or 7080.2400 (Advanced Inspector |
|
|
||
License required) |
|
|
||
Drainfield meets the designed vertical |
|
|
||
separation distance from periodically |
|
|
||
saturated soil or bedrock. |
|
|
||
|
|
|
|
|
Verification method(s):
Soil observation does not expire. Previous soil observations by two independent parties are sufficient, unless site conditions have been altered or local requirements differ.
Conducted soil observation(s) (Attach boring logs)
Two previous verifications (Attach boring logs)
Not applicable (Holding tank(s), no drainfield)
Unable to verify (See Comments/Explanation)
Other (See Comments/Explanation)
Comments/Explanation:
Indicate depths or elevations
A.Bottom of distribution media
B.Periodically saturated soil/bedrock
C.System separation
D.Required compliance separation*
Any “no” answer above indicates the system is failing to protect groundwater.
*May be reduced up to 15 percent if allowed by Local Ordinance.
5. Operating Permit and Nitrogen BMP* – Compliance component #5 of 5
Not applicable
Is the system operated under an Operating Permit?
Is the system required to employ a Nitrogen BMP?
Yes
Yes
No If “yes”, A below is required No If “yes”, B below is required
BMP = Best Management Practice(s) specified in the system design
If the answer to both questions is “no”, this section does not need to be completed.
Compliance criteria
a. |
Operating Permit number: |
|
|
Yes |
No |
|
Have the Operating Permit requirements been met? |
||||
|
|
|
|||
b. |
Is the required nitrogen BMP in place and properly functioning? |
Yes |
No |
||
Any “no” answer indicates Noncompliance.
Upgrade Requirements (Minn. Stat. § 115.55) 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 shorter period if required by local ordinance. If the system is failing 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 defined in law, and has at least two feet of design soil separation, then the system need not be upgraded, repaired, replaced, or its 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 food, beverage, and lodging establishments as defined in law.
www.pca.state.mn.us • |
• |
TTY |
||
|
|
|
Page 3 of 3 |