08-19-2022 Septic Compliance Inspection Report

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M MINNESOTA POLLUTION Sewage tank integrity assessment form CONTROL AGENCY integrity 520 Lafayette Road North Subsurface Sewage 5t. Paul, MN 55155-4194 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 form 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 Ilwww pca.state.mn us/waterimspections Instructions: This form may be completed, and signed by a Designated Certified Individual (DCI) 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 lank 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 he 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: Coat mance inspection. form - Exis*riq system 1wQ viviists4-31 b This form can be found on the MPCA website at nttps !Iwmnvpca state mn us/wateffinspection . The informalton 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 an inspection report This form represents a third party assessment of SSTS component compliance and is allowable under Minn R 7082 0700 subp 4(B)(1). This foram 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 owners 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(C) Owner information Owner/Representative Bill Hunt Property address 125 Truffala Trail Orono, MN 55356 Local Regulatory Authority: System status System status on date (mmlddlyyyy) 8111/2022 Parcel ID: Q 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 ❑Yes' ®No Groundwater." The SSTS has a sewage tank that leaks below the designed operating depth - "Failure to Protect Yes' ®No Groundwater." El 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' 2 No Public Health or Safety." Any "yes" answer above indicates sewage tank non-compliance. Company information Designated Certified Individual (DCI) information Company name: Elmer J Peterson Co Business license number 219 Print name James L Braegelmann Certification number I personalty conducted the work described above as a Designated Certified Individual of a Minnesota -licensed SSTS inspection, maintenance. installation or service provider Business I personally conducted the necessary procedures to assess the compliance status of each sewage tank in this SSTS By typinglsigning my name below. 1 certify the above statements to be true and correct to the best of my knowledge and that this infomralion can be used for the purpose of processing this form. Designated Certified Individual's signature James L Braegelmann Date (mmidd/yyyy) 8111/2022 (This document has been electronically signed..) www.pcastate.mn.us • 651 296-6300 800-657 3864 • Use your preferred relay service Available in alternative formats wq-wwists4-91 • 5/10/21 Page 1 of I