Mpca Compliance Inspection Form – Fill Out and Use This PDF

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:

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.)

Necessary or Locally Required Attachments

Soil boring logs

System/As-built drawing

Other information (list):

Forms per local ordinance

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 system/D-boxes Homeowner testimony

“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)

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)

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 non-protective of ground water for other conditions as determined by inspector .

Yes*

*System is failing to protect groundwater.

Explain:

Yes*

Yes*

No

No Unknown

No Unknown

	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 two-foot vertical
	separation distance from periodically
	saturated soil or bedrock.
	Non-performance systems built April 1,		Yes	No
	1996, or later or for non-performance
	systems located in Shoreland or Wellhead
	Protection Areas or serving a food,
	beverage, or lodging establishment:
	Drainfield has a three-foot vertical
	separation distance from periodically
	saturated soil or bedrock.*
	“Experimental”, “Other”, or “Performance”		Yes	No
	systems built under pre-2008 Rules; Type IV
	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