07/05/2020 Septic Compliance Inspection

Home Browse Search

Property address: 2400 Fox Street _ City: Orono State: MN Parcel ID: 0411723410011 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 (1301) 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 (wq-wwists4-31b. This form can be found on the MPGA website at httos:l!www.Dca,state.mn.us/waterissts-and-msts-te_c_hnical-and-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 date 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. Z Certificate of sewage tank compliance Affirm all three statements: M The SSTS does not contain a seepage pit, cesspool, drywell, leaching pit, or other pit. ® It does not contain a sewage tank that was designed to be watertight, but subsequently leaks below the designed operating depth. ® It does not represent an imminent safety threat by reason of unsecured, damaged, or weak maintenance hole cover(s) or other unsafe condition. Company information Company name: Chip Septic Services _ Business license number: 2064 ❑ Notice of sewage tank non-compliance Select all that apply: ❑ The SSTS has a seepage pit, cesspool, drywell, leaching pit, or other pit. ❑ It has a sewage tank that was designed to be watertight, but subsequently leaks below the designed operating depth. ❑ It presents a threat to public safety by reason of unsecured, damaged, or weak maintenance hole cover(s) or other unsafe condition. Designated Certified Individual (DCI) information Print name: Perel Hentges__ Certification number: I personally conducted the work described above as a Designated Certified Individual of a Minnesota -licensed SSTS Maintenance Business. I personally conducted the necessary procedures to assess the compliance status of each sewage tank in this SSTS: Designated Certified Individual's signature: _ _ Date (mm/dd/yyyy): 06/3012020 www.pca.state.mn.us • 651-296-6300 • 800-657-3864 Use your preferred relay service wa-wwists4-38 . 1127117 Available in alternative formats Pace 3 of 3