05-24-2023 Septic Compliance - Laserfiche WebLink

Home Browse Search

David & Michelle Denniston Property address: 1200 Phillip s Drive city: Orono - Medina _ _ State: MN Orono PID# 2711823320009 Medina PID# 2711823230002 Parcel ID: Zip code:_ 55356 Optional section: Sewage Tank Compliance Certification This form doss not represent a complete system tnepeodon report and only certifies sewage tank compliance status. Inst mesons: This section of the form may be cornpleted and signed by a Designated Certified Individual (DCI) of a licensed SSTS Maintenance Business who personalty 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 neaessefy supporting documentation to an Existing System Compliance Inspection Report: Compliance insR@Oon f 1 t . This form can be found on the MPGA website at htto :/ oca state mn uglMortssts-and :msts-tochn_icai-and-camAllance-crit$na. 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 (s) 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 Mms B, C, and D; 7083.0730 Um C. ® Certificate 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 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: Albin's 8e kPurnpin_ g, LLC Business license number: 3346 ❑ Notice of sewage tank non-compliance Select all that apply: ❑ The SSTS has a seepage pit, cesspool, drywell, leaching pit, or other ph. ❑ 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 (I)CQ Information Print name: Peter Peterson Certification number. 9227 I personally conducted the warlc described above as a Designated Certified individual of a Minnesotadicensed SSTS Maintenance Business. ! personally conducted the ry pmoodures to assess the compliance status of each sewage tank in this SSTS: Designated Certified Individual's signature: _ Date (mm/dWyyyy): _ 05/18/2023 www.pca.state.mn.us • 651-296-63M 806.657-3864 Use your preferred relay service Available in altemative formats wq-wwists4.38 • 1127117 Paye 3 of 3