01-31-2020 Septic Compliance - Laserfiche WebLink

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Property address: 920 Wayzata Blvd _ _ _ . Parcel to: 35-118-23-41-0006 city: Orono _ state. MN zip code: 55391 _ Optional section: Sewage Tank Compliance Certification This form does not represent a complete system inspection report and only certifies sewage tank compliance status. Instructions: This section of the form may be completed and signed by a Designated Certified individual (DCI) of a licensed SSTS Maintenance Business who personally conducts the necessary procedures to assess the compliance status of each sewage tank in the system. When this section of the form is signed by a qualified certified professional, it becomes necessary supporting documentation to an Existing System Compliance Inspection Report: Compliance inspection form - Existing system w -wwi -31W. This form can be found on the MPGA website at httos:/fwawr.oca,state.mn.us/water/ssts and-msts4echnical- nd-compliance-criteria. The information and certified statement on this form is required when existing septic tank compliance status is determined by an individual other than the SSTS Inspector that submits the inspection report. It represents a third party assessment of SSTS component compliance and is allowable under Minn. R. 7082.0700, subp. 4 Item (B) subitem (1). This form is valid for a period of three years beyond the signature dale on this form unless a new evaluation is requested by the owner or owner's agent or is required according to local regulations. Additional Administrative Rule references for this activity can be found at Minn. R. 7082.0700, subp. 4 Items B, C, and D; 7083.0730 Item C. XCertificate of sewage tank compliance ❑ Notice of sewage tank non-compliance irm all three statements: Select all that apply: The SSTS does not contain a seepage pit, cesspool, ❑ The SSTS has a seepage pit, cesspool, drywell, rywell, leaching pit, or other pit. leaching pit, or other pit. It does not contain a sewage tank that was designed ❑ It has a sewage tank that was designed to be be watertight, but subsequently leaks below the watertight, but subsequently leaks below the designed SSuf�lesigned operating depth. operating depth. It does not represent an imminent safety threat by ❑ it presents a threat to public safety by reason of ason of unsecured, damaged, or weak unsecured, damaged, or weak maintenance hole maintenance hole cover(s) or other unsafe condition. cover(s) or other unsafe condition. Company information Company name: Albin'sSeptiie Pumping LLC _ Business license number. 3346 _.. Designated Certified Individual (DCI) information Print name: Peter Peterson Certification number: 9227 1 personally conducted the work described above as a Designated Certifiers Individual of a Minnesota -licensed SSTS Maintenance Business. l personally conducted the no ary procedures to assess the compliance status of each sewage tank in this SSTS: Designated Certified 06/f)512019 Individual's signature: t Date (mmlddlyyyy): _ www.pca.state.mn.us • 651-296.6300 800•657.3864 use your preferred relay service Available in alternative formats wq-wwists4-38 • 1127/17 Page 3 of 3