Fillable Affidavitof Compliance Installers Affidavit Of Compliance Form (Minnesota Department of Revenue)

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Affidavitof Compliance Installers Affidavit Of Compliance Form (Minnesota Department of Revenue)

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Property Owner:
Parcel ID: Phone Number:
Property Address:
Mailing Address (if different):
Legal Description (from deed/abstract):
Township: Section:
SSTS Permit #: Operating Permit #:
1.)
2.) Existing tanks are required to be properly abandoned.
3.) Portions of required supply pipe were not installed or complete at the time of original inspection.
4.) A pressure test is required for all piping less than 50 feet from your well. (fill in below)
5.)
6.) A redesign is needed due to alterations in the system at the time of installation. (consult designer)
7.) A warranty form is required for the soil dispersal system as installed at MPCA warranty sizing.
8.) An elevation verification is required to verify your new SSTS meets flood plain elevation requirements. (fill in below)
9.) A water tightness verification is required to be submitted for the tanks utilized in your new SSTS. (fill in below)
10.) Other:
This is to certify that the buried sewer(s) described below is/are within 50 feet but are no closer than 20 feet of
Minnesota Unique Well Number located on the property listed above.
The subject buried sewer(s) is/are constructed of the following materials:
ABD (ASTM D2751) ABS (ASTM D2661) ABS (ASTM F628)
Other:
LIST BELOW
PVC (ASTM D2665) PVC (ASTM D3034) PVC (ASTM D3033)
PVC (ASTM F789) PVC (ASTM F891) Cast Iron
Pressure Test Affidavit
The portion of the buried sewer system tested is described and diagramed
on the attached site drawing.
Air test
(5 psi constant pressure for 15
minutes)
Manometer Test
(1 inch of water column)
Vacuum Test for manholes
(ASTM C-924)
Incomplete Installation Items
Septic tank(s), elevated manhole access points, controls, pump(s), switches, insulation, and/or flow
measurement devices were not installed or complete at the time of original inspection.
The soil dispersal system was not complete at the time of original inspection. This may include but
not limited to missing dispersal media, pipework, sand, fabric, and /or inspection ports.
Permit/Parcel/Owner Information:
StearnS County environmental ServiCeS
SubSurfaCe Sewage treatment SyStem
inStallerS affidavit of ComplianCe form
705 Courthouse Square Administrative Center Rm 343
St. Cloud, Minnesota 56303 (320) 656-3613 or 1-800-450-0852
FIRM panel on which property is located:
FIRM map zone in which property is located:
FIRM effective date:
Ten year flood elevation at proposed site: Feet above mean sea level
Feet above mean sea level
One hundred year flood elevation at proposed site: Feet above mean sea level
FIELD VERIFIED:
The elevation of the bottom of the distribution media of this system is: Feet above mean sea level
The elevation of finished grade at the top of the soil dispersal system is: Feet above mean sea level
Verifiers name:
Verifiers title:
Address:
Phone number:
License #:
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If raising elevation (mound systems) then
the ten year flood elevation plus one-half
(.5) foot is required at proposed site:
In accordance with Minnesota Statutes, section 144.992, persons submitting false information to the Minnesota Department
of Health are subject to administrative penalties of up to $10,000.
Flood Plain Elevation Verification
Date:
Signature of Verifier:
If different
from Installer
Contaminated materials* removed and disposed off site?
All solids removed from all tanks?
Disposal Site:
All electrical devices and devices containing mercury removed?
Disposal Site:
Future discharge to system permanently denied?
Disposal Site:
*Contaminated materials = Distribution media, soil 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 subpart 3.)
**Underground cavities = Cesspools, leaching pits, drywells, seepage pits, vault privies, pit privies, pump chambers (7080.2500
subpart 1). Doers not include chamber media, drop boxes, or distribution boxes.
Disposal Site:
All underground cavities** crushed and filled with clean material? -OR-
Removed and disposed off site?
Disposal Site:
SSTS Abandonment Verification
All underground sewage tanks crushed and filled with clean material? -OR-
Removed and disposed off site?
Disposal Site:
Tank used for: MSTS
Type of test: Water Vacuum
Model of tank Date of test Test performed by
License #:
Installation Business:
License #:
Phone number:
Date:
Signature of Installer:
STATEMENT: I hereby certify the system was abandoned in accordance with Minnesota Rules 7080.2500 and any local
requirements.
STATEMENT: I hereby certify that the SSTS installed at the above identified property complies with all provisions of the Stearns
County Subsurface Sewage Treatment System Ordinance #422, or successor ordinances; and also all applicable requirements
prescribed in Minnesota Rules, chapters 7080 through 7083, or successor rules.
SSTS Professionals Certified Statements
Date:
Signature of Certifier (If different from Installer)
STATEMENT: I hereby certify that the above listed model(s) have completed watertight testing, as required in Minnesota Rules,
parts 7080.2290 B. and 7081.0240 subpart 5; or successor rules.
STATEMENT: I hereby certify that the above listed model(s) have completed watertight testing, as required in Minnesota Rules,
parts 7080.2290 B. and 7081.0240 subpart 5; or successor rules.
STATEMENT: This buried sewer has/have been constructed of cast iron or plastic piping materials meeting the standards of the
Minnesota Plumbing Code, part 4715.0530 and that the subject buried sewer(s) has/have been tested in accordance with part
4715.2820 and has/have passed an Air Test/Manometer Test.
STATEMENT:
I hereby verify that the above listed elevations are true and accurate measurements of the SSTS located at this
property; and that the SSTS meets or exceeds the required elevations as prescribed in Minnesota Rules, part 7080.2270; or
successor rules.
Tank Water Tightness Certification:
Holding Tank
A sketch showing all applicable items from the following list shall be provided below.
• Well location and depth • Indicate the portion of the piping that was tested
• •
• Dimensions of the newly constructed SSTS
• Soil treatment dispersal media type and depth • A permanent reference point(s) and dimensions
• • Other information as requested
As-built Sketch Requirements
Measurements to all required SSTS setbacks ( i.e.
wells, property lines, structures, OHWL)
Depth of final cover over soil treatment area and
sewage tanks
Location of all abandoned septic tank(s), soil
dispersal system, cesspools, seepage pits and
other pits.
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Affidavitof Compliance Installers Affidavit Of Compliance Form (Minnesota Department of Revenue)

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Completed 18 July 2020

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