705 Old Long Lake Road - Septic Compliance

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Property address: 705 Old Long Lake Rd Parcel ID: 36-118-23-32-OON City: Orono State: MN Zip code: 55391 Optional section: Sewage Tank Compliance Certification (Tank integrity assessment) This form does not represent a complete system Inspection report and only certlfEes sewage tank compliance status. i.e., this form, completed, may serve as a tank Integrity assessment. Instructions: This section of the form may be completed and signed by a Designated Certified Individual (DCI) of a licensed SSTS Maintenance 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 supporting documentation to an Existing System Compliance Inspection Report: Compliance Inspection fo - Existing s s m w-wwists4- 1b . This foam can be found on the MPCA website at https:Nwww.pca.state.mn.usAmatertservice-and-maintenance. 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 Item (B) 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 Items B, C. and D; 7083.0730 Item C. Pages 1 and 2 are not required to accompany this form when the optional third page is completed and used to certify sewage tank compliance status. system status System status on date (mmlddlyyyy): 412M025 4:p t `tQ r �Cert€ficate of sewag p to of sa tank compliance CE f ewage tank noa-compliance Compliance criteria: The SSTS has a seepage pit, cesspool, drywell, teaching pit, or other pit -'Failure to Protect ❑Y�� o Groundwater." The SSTS has a sewage tank that leaks below the designed operating depth -"Failto Protect [I Yes" �iVo Groundwater." The SSTS presents a threat to public safety by reason of structurally unsound (damaged, cracked, or ❑ Yes' PNo weak) maintenance hole cover(s) or lids or any other unsafe condition -'Imminent Threat to Public Health or Safety." Any 'ryes" answer above indicates sewage tank non-compliance. Company Information Designated Certified Individual [DCI) information Company name_ Kothrade Sewer. Water & Excavatlnp Inc Print name: Larry Bursch _ Business ilcense number: MPCA 192 Certification number. C9189 I personally conducted the work described above as a Designated Ceffrfred Individual of a Minnesotadicensed SSTS Maintenance Business. !personally conducted the necessary procedures to assess the compliance status ofeach sewage tank in this SSTS. By typing/signing my name below, I certify the above statements to be true and correct, to the best of my knowledge, and that this Inh mratian can be used for the purpose of proses g this form. Designated Certified Individual's signature: Date (mrnldd/yyyy): www.pcastate.mn.us 651-296.6300 800 657-3864 • Use your preferred relay servke Available In altamatft formats wq wwlsts4-38 • 0/2&21 PW343