12/19/2022 Septic Compliance - Laserfiche WebLink

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Property address: 4.040 Watertown_ Rd Adam &Hannah Westlinc) Parcel ID: 3111823410001 city: Orono state:_ MN _ _ zip code:_55359 _ section: Sewage Tank Compliance Certification This form does not repissent a complete system inspection report and only csrtliies sewage Instructions: This seen of the form may be completed and signed by a Designated Certified individual (DCI} of a tswnsed btj 15 Maintsnarm 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 suppofft rbowirw1afian to an Existing System Compliance Inspection Report: Compliance inspection fa - . This form can be found on the MPCA webiae at The information and certilled 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 surd is allowable under Minn. R. 7082.0700, subp. 4 Item (B) subiitem (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 adMty can be found at Minn. R. 7082.0700, subp. 4 Items B, C, and D; 7083.0730 Item C. ]MCwUfieate of sewage tank compliance Affirm all three statements: �( 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 wateftight, but subsequently leaks below the designed operating depth. X It does not represent an imminent safety threat by reason of unsecured, damaged, or weak maintenance We cover(s) or other unsafe condition. Company lnformatlon Company name: Albin''s Se ' _Pumping, LLC ❑ 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 pubtic safety by reason of unsecured, damaged, or weak maintenance hole covers) or other unsafe condition. Designated Certified Individual (DCI) Inibrmatlon Print name: Peter Peterson Business license number: 3346 Certification number: 9227 I personafy conducted Re work described above as a Designated Ceram ln&Wdual of a Minnesota- icensed SETS Mahrtenance Business. I permw0y conducted the ry pmcedures to assess the compliance status of each sewage tank in this SSTS: Designated Certified Individual's signature: y % _ flare (mwddlyyyy): _ 11/25/2022 www.pca.stat,e.mn.us . 651-2%-6300 • 800.657-3864 Use your preferred relay service Available in alternative formats wq-ww1at34-3d • 1127117 page 3 of 3