605 Stubbs Bay Road North - Septic Compliance - 2025

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Property address: 605 Stubbs Bay Rd N Parcel ID: 32-118-23-21-0005 City: Orono State: MN Zip code: 55356 Optional section: Sewage Tank Compliance Certification (Tank integrity assessment) This form does not represent a complete system inspection report and only certifies 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 form - Existing system (wa-wwists4-31 b). This form can be found on the MPCA website at https://www.pca.state.mn.ustwater/service-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 (mm/dd/yyyy): 5/29/2025 —/Ok)J certificate of sewage tank compliance ❑ Notice of sewage tank non-compliance Compliance criteria: The SSTS has a seepage pit, cesspool, drywell, leaching pit, or other pit - "Failure to Protect ❑Yes" �Jo Groundwater." f The SSTS has a sewage tank that leaks below the designed operating depth - "Failure to Protect ❑ Yes" [ No Groundwater." The SSTS presents a threat to public safety by reason of structurally unsound (damaged, cracked, or El Yes- �No weak) maintenance hole cover(s) or lids or any other unsafe condition - "Imminent Threat to Public Health or Safety." Any "yes" answer above indicates sewage tank non-compliance. Company information Company name: Kothrade Sewer, Water & Excavating Inc Business license number: MPCA 192 Designated Certified Individual (DCI) information Print name: Larry Bursch Certification number: C9199 I personally conducted the work described above as a Designated Certified Individual of a Minnesota -licensed SSTS Maintenance Business. I personally conducted the necessary procedures to assess the compliance status of each 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 information can be used for the purpose of proce§sing this form. Designated Certified Individual's signature: Date (mm/dd/yyyy): $' 2 i- ZS— www.pca.state.mn.us 651-296-6300 800-657-3864 Use your preferred relay service Available in alternative formats wq-ww1sts4-38 • 4128122 Page 3 of 3