08-21-2022 Septic Compliance Inspection report

Home Browse Search

Property address: 2.790 White Oak Circle icholas & Suzanne Hansen.) Parcel lo; 0411723420016 city. Orono state: M N _ zip code: 55356 -Optional section: Sewage Tank Compliance Certification This form does not represent a campiete spm inspection report and only certifies sewage tank compliance statue. Irmtructionsed certified Individual of a ticensed SSTS Maintenance lBusines o personection at the alty conducts themay be pleted and r awry proed by a cedures too assess the compliance status ofl)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 Systsm Compliance Inspection Report Com2 lance ins pe don tom - Facistino s; 9+�rn fv�a rvwists4 This form can be found on the MPCA website at hM:/A~Dca,staia.mn.us �ra=.r.a'e_+""finical and-0ornolian -criteria. The information and certified statement on this Than 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 farm 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 C; 7083.0730 Item C. IM Certificate of sewage tank compliance Affirm all three statements: ® The SSTS does not contain a seepage pit, cesspool, drywell, leaching pit, or other pit. b containit does not io be watertight� but sudesigned subsequently leaks ks belovw 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. [� Notice of sewage tank non-compliance Select all that apply: The SSTS hes a seepage pit, cesspool* drywall, leaching pit, or other ph. D it has a sewage tank that was designed to be watertight, but subsequently leaks below the designed operating depth. It presents a threat topublic safety by reason of unsecured, damaged, or weak maintenance hole cover(s) or other unsafe condition. Company Information Designated Certified Individual (DCI) information Company name: Albin's Se Pumping, LLC _ Print name: Peter Peterson _ Business license number: 3346_ Certification number. 9227 -- - . -- - -- I personally conducted the work described above as a Designated Certified individual of a Minneade-licensed SSTS MainienarcG Business. t personally cond�sd the n ry procedures to assess rile compliance status of each sewage tank in finis SSTS: Designated Certified 08/15/2022 individual's signature: __ Cate (mmldd/yyyy): _ www.pca.state.mn.us . 651-296-63W • 800-657-3864 use your preferred relay service • Available in aittemttve formats wq-wwists4-38 • 1127117 Page 3 of 3