08-21-2022 - SE22-000026- 2790 White Oak Circle letter and cert

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Property address: City: Orono 2790 White Oak Circle (Nicholas & Suzanne_ Hansen) Parcel to: 0411723420016 State: MN _ Zip code: _55356 -- - f optional section: Sewage Tank Compiiance Certification This form does not represent a complete syatam inspection report and only certifies sewage tank compliance status. Inafte lone: This section of the form may be completed and signed bya Designated ssess Caritified complianceIividual status of each of sewage tank � Maintenance Business who personally conducts the necessary prone the system. When this section of the form is signed by a qualified certified professional, ti becomes necessary supportng documentabon to an I i fo s tem . This form can be Existing Sylreem Compliance Inspection Report: •a. found on the MPGA webrde at h -m ! - - -cc The information and certirred statement on this form is mquirred 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. 7062.0700, subp. 4 Item (B) subitem (1). This form Is valid for a period of throe years beyond the signature date on this form unless a new evaluation is requested by the owner or owner's agent or is required aocording to local regulations. Additional Administrative Rule references for this activity can be found at Minn. R. 7082.0700, subp. 4 Nems B. C, and 0; 70133.0730 Bern C. IN Certiflcalle of seWS6 tank compliance Affirm all three statemenffi: ® The SSTS does not contain a seepage pit, cesspool, drywall, 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 unsawred, damaged, or weak maintenance We cover(s) or other unsafe condition. ❑ Notice of sewage flank 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 topublic safety by reason of unsecured, damaged, or weak maintenenoe hole cover(s) or other unsafe condition. Company Information Designated Certified Individual (DCI} information Company name: Altrin's Se ' „Pumping, LLC T _ _. Print name: Peter Peterson Business license number: 3348_ Certification number: 9227 -- _ I personaffy conducted lice work described above as a Designated Ce~ individual of a Mrnnesofa4cwwd SSTS Makdenance Business. t personalty conducted the ry prnaedufes to assess the compliance status of each sewage twnic in this SSTS: Designated Certified nate (miWW" y)� _08/15/2022 Individual's signature: -- www.pca.state.mn.us A • 651-296.6300 • ' 800-657-3854 •— Use your preferred relay service 0 Available to Atemadve formats wq-ww1sts4.38 • 1127117 Page 3 of 3