HomeMy WebLinkAbout05-29-19 Sewage Tank Compliance CertificatePly address:
2425 Thoroughbred Lane (Colin & Julie Davie) _
Parceei lD:
04117'23110018
City: Orono
_ State:. M N
_ zip code:
55356
Optional section: Sewage Tank Compliance Certification
This form does not represent a cornpleft system inspection report and only eerdf'lea sewage tank compliianc 811:211M.
s.
insinuations: This erection of the form may be completed and signed by a Designated Certified Individual (DCI) of a ii muW SSTS
Mahftm rmoe Business who personally conducts the necessary procedures to assess the compliance edatus of each sewage tank in
the system.
VVherr this section of the form is signed by a qualified certified professional, it becomes necessary supporthV documentafm to an
Existing System Compliance Inspection Report: QgWience i This form can be
found on the MPGA website at
The information and certified statement on this form is required when ekisfjng septic tank compliance status is determined by an
Individual other than the SSTS Inspector that submits the inspection report. It nrpresenfs a third party assessment of SETS
=7ponent compliance and is allmmUe under Minn. R. 7482.0700, subp. 4 stern (8) sulxtern (1). This fame is valid for a period of
three yews beyond the signature date on this form unless a new evaluation Is requested by the owner or oawWs agent or Is
required according to local regulations. Additional Administra dve Rule references for this activity can be found at Minn.
R. 7082.4700, subp. 4 items B, C, and D; 7083.0730 item C.
IN {s tiftsta of swage tank compiianc*
Affirm all three staterr%K ts:
$I The SETS does not contain a creepage pit, cesspool,
drywel, feesed hV pit, or other pit.
It does not contain a sewage tank that was designed
to be wa*t, but sube;squently kraks below the
designed operating deepth.
]$� It does not represent an imminent safety threat by
reason of unsecured, damaged, or weak
maintenance hole cover(s) or other unsafe condition.
Company infonnafion
Company narne: Albin's Septic Pum&g, LLC
E] 14otice of seiwgp tank non -c rnpillancte
Select all that appy.
0 The SSTS has a seepage pit, cesspool, drywall,
leaching pit, or other pit.
It has a sewage tank that was designed to be
watertight, but subsequently leaks below firs designed
operating depth.
❑ It presents a threat to public safety by reason of
unsecured, damaged, or weak mahtenarrce thole
cover(s) or other unsafe card`ition.
Designated Certified Indhridual (DCll Inforrrtatlon
Print name: Peter Peterson
Business license number: 3348 Ced!fK:aWn number. 9227
I pwWaafly cWdrrctad the work described above as a Designated Cerfftd Individual of a Minnese tb4csnsed SSTS Mairderrsrrae
BuaV?ess, I persormYy carr fed the ry procedures to assess the car "poarrcee status of each saw age tank in this SETS:
Desufrs � : - Date (mnvdd►yyyy):05/29/2019
www.pa.statemn.us . +651-296-53110 • M657-3854 U$e your preferred relay service Avalt#ble in atternat:ive formats
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