08-17-2022 Septic Compliance - Laserfiche WebLink

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1 MINNESOTA POLLUTION Sewage tank integrity assessment farm CONTROL AGENCY 524 t-afayette Road North Subsurface Sewage St. Paul, MN 55155-4144 Treatment Systems (SSTS) Program Doc Type Compliance and Enforcement Purpose: This form may be used to certify the compliance status of the sewage tank components of the SSTS. This fon►'/ is not a complete SSTS inspection report. only a tank integrity assessment, and may only certify sewage tank compliance status when entirely completed and signed by a qualified professional. SSTS compliance inspection report forms can be found at https llwww pca state mn us/wateritnspe-ior?s, Instructions: This form may be completed, and signed, by a Designated Certified Individual (DCII of a licensed SSTS inspection. maintenance, installation, or service provider business who personally conducts the necessary procedures to assess the compliance status of each sewage tank in the system Only a licensed maintenance business is authorized to pump the tank for assessment. A copy of this information should be submitted to the system owner and be maintained by the licensed SSTS business for a period of five (5) years from the assessment date When this form is signed by a qualified certified professional, it becomes necessary supporting documentation to an Existing System Compliance Inspection Report: QpjDpharice insoectian foie• Existing system (wq-wwists4-310 This form can be found on the MPGA website at httiDr 1'wvrw oca state mn ushvaterlinsoectio,rr_ 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 Inspecior that submits an inspection report This form represents a third party assessment of SSTS component compliance: and is allowable under Minn R 7082.0700, subp 4(6)(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(B) (C). and (D) and: Minn R 7083.0730(Cl Owner information Owner/Representative Lynn Johnston Property address 2140 Salem Court Orono, MN Local Regulatory Authority, Parcel ID System status System status on date (mmiddiyyyy) 6/30/2022 Certificate of sewage tank compliance ❑ Notice of sewage tank non-compliance Compliance criteria: The SSTS has a seepage pit, cesspool, drywell leaching pit or other pit - "Failure to Protect Ll Yes` 0 No Groundwater." The SSTS has a sewage tank that leaks below the designed operating depth - 'Failure to Protect [] Yes- 0 No Groundwater." The SSTS presents a Threat to public safety by reason of structurally unsound (damaged. cracked. or weak) maintenance hole cover(s) or lids or any other unsafe condition - 'Imminent Threat to ❑ Yes- iD No Public Health or Safety." Any "yes answer above indicates sewage tank non-compliance. Company information Company name Elme r J. Peterson Co Business license number 219 Designated Certified Individual (DCI) information Print name: James L Braegelmann Certification number I personally conducted the work described above as a Designated Certifier/ Individual of a Minnesota -licensed SSTS inspection, maintenance. installation. or service provider Business 1 personally conducted the necessary procedures to assess the compliance status of each sewage tank in this SSTS By typingfsigning my name below t certify the above statements to be true acid correct. to the hest of nay knowledge. and that this infonnation cat) be used for the purpose of processing this form Designated Certified lndividuafs signature: James L Braegelmann Date (mml'ddiyyyy) 6130/2022 (This document has been electronically segned ) www.pca.state.mn.us b5i 296-6300 800-557-39(A use your preferred relay service Available in alternative formats wQ-wwi5ts4 91 • 511012I Poge 1 of 1