820 Old Crystal Bay Road South - Septic Compliance

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i INNESOTA POLLUTION Sewage tank integrity rit assessment form CONTROL AGENCY 520 Lafayette Road North Subsurface Sewage St. Paul, MN 55155-4194 Treatment Systems (SSTS) Program Doc Type: ConWilarx a and Entomsment Purpose: This form may be used to certify the compliance status of the sewage tank components of the SSTS. This form Is not a complete SSTS inspection report, only a tank integrity assessment, and may only certify sewage tank compliance status when entirely completed and signed by a qualified professional. SSTS compliance inspection report forms can be found at https://www.gca.state.mn.us/water inspecti ns. Instructions: This form may be completed, and signed, by a Designated Certified Individual (DCI) of a licensed SSTS Inspection, maintenance, installation, or service provider business who personally conducts the necessary procedures to assess the compliance status of each sewage tank in the system. Only a licensed maintenance business is authorized to pump the tank for assessment. A copy of this Information should be submitted to the system owner and be maintained by the licensed SSTS business for a period of five (5) years from the assessment date. When this form Is signed by a qualified certifted professional, it becomes necessary supporting documentation to an Existing System Compliance Inspection Report: Comoliance inspection form - Existing systgM (wq-wwists4-31 b). This form can be found on the MPCAwebsits at httos:/iwww.2ca.state.mn.us/waterfinspections. 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 an inspection report. This form represents a third party assessment of SSTS component compliance and is allowable under Minn. R. 7082.0700, subp. 4(B)(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 owners 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(B),(C), and (D) and; Minn. R. 7083.0730(C). 2- 100-01--> Owner information Owner/Representative Property address: St 40 _fit ek C r t />< r C \ Local Regulatory Authority: ifr 0^0 System status System status on date (mm/dd/yyyy): _C Parcel ID: Elbel ficate of sewage tank co(npliance ❑ Notice of sewage tank non-compliance Compliance criteria: �, The SSTS has a seepage pit, cesspool, dryweli, leaching pit, or other pit - `Failure to Protect [J Yes* [d, o Groundwater." The SSTS has a sewage tank that leaks below the designed operating depth - "Failure to Protect ❑ Yes* ErN000 Groundwater." The SSTS presents a threat to public safety by reason of structurally unsound (damaged, cracked, or weak) maintenance hole cover(s) or lids or any other unsafe condition - "Imminent Threat to ❑ Yes* ;;tad" Public Health or Safety." Any "yes" s"'17s—wvi above indicates saiw gg tank non-conatafle ca. Company information Designated Certified individual (DCI) information Company name: Duane's Septic Service LLC Print name: - l't c Business license number L4286 Certification number. ($' ( % 1 personally conducted the work described above as a Designated Certified Individual of a Minnesota -licensed SSTS inspection, maintenance, installation, or service provider Business / personally conducted the necessary procedures to assess the compllance status of each sewage tank In this SSTS. By typing(slgning my name below, I certify the abov statements to be true and correct, to the best of my knowledge, d that this information can be used 1br the purpose of p s ing this : �, Designated Certified Individual's signature: Date (mm/dd/yyyy): a� (This n been a ec icaW signed.) www.pca.state.mn.us 651-296-M NO-657-3KA • Use your preferred relay service Available In alternative formats wq-ww1sts4-91 • 5/I0/21 Page 1 of 1