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<br />https://www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • Use your preferred relay service • Available in alternative formats <br />wq-wwists4-31b • 4/28/2021 Page 2 of 4 <br /> <br />Property Address: 450 Orono Orchard Rd South Orono MN 55391 <br />Business Name: Rotz Septic & Excavating Date: 9/4/2025 <br />1. Impact on public health – Compliance component #1 of 5 <br /> Compliance criteria: Attached supporting documentation: <br /> System discharges sewage to the <br />ground surface <br /> Yes* No Other: <br /> Not applicable <br /> System discharges sewage to drain <br />tile or surface waters. <br /> Yes* No <br /> System causes sewage backup into <br />dwelling or establishment. <br /> Yes* No <br /> <br /> <br />Any “yes” answer above indicates the system is an <br />imminent threat to public health and safety. <br /> Describe verification methods and results: <br />Visual inspection of the immediate area could not identify any type of ITHS . <br />2. Tank integrity – Compliance component #2 of 5 <br /> Compliance criteria: Attached supporting documentation: <br /> System consists of a seepage pit, <br />cesspool, drywell, leaching pit, <br />or other pit? <br /> Yes* No Empty tank(s) viewed by inspector <br /> Name of maintenance business: Rotz <br /> Sewage tank(s) leak below their <br />designed operating depth? <br /> Yes* No License number of maintenance business: L3987 <br /> Date of maintenance: 9/4/2025 <br /> Existing tank integrity assessment (Attach) <br /> <br />If yes, which sewage tank(s) leaks: <br /> Date of maintenance <br />(mm/dd/yyyy): <br /> <br />(must be within three years) <br /> Any “yes” answer above indicates the system <br />is failing to protect groundwater. <br /> (See form instructions to ensure assessment complies with <br />Minn. R. 7082.0700 subp. 4 B (1)) <br /> Tank is Noncompliant (pumping not necessary – explain below) <br /> Other: <br /> Describe verification methods and results: <br />All Baffles (Poly) observed to be in place. <br /> <br />