HomeMy WebLinkAbout05/20/2020 Sewage tank compliance formPropyaddress; 2775 Deer Run Trail East (Jeffrey & Sandra Praus) Parcel ID: 04-117-23-13-QQ15
city: —Orono state. MN _ zip code:_ 55356 _.
optional section: Sewage Tank Compliance Certification
This form does not represent a complote system Inspection report and only certifies sewage tank compliance staM.
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,
Existing System Compliance Inspection Report: 9csnpiIMM ins ion_fon
found on the MPCA website at htto 2AMffi oca state mn u�lwater/ssts-and
Yrentamno to an
hie form can be
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 Inspect that submits the inspection report. It 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 Rem C.
)% Certificate of sewage tank compliance
Affirm all three statements:
The SSTS does not contain a seepage pit, cesspool,
drywell, leaching pit, or other pit.
it does to be wartertlghntain a t, but subsegquuenily leak below bele tank that was the e
designed operating depth,
it does not represent an imminent safety threat by
reason of unsecured, damaged, or weak
maintenance hole cover(s) or other unsafe condition.
Company Information
Company name: Nbin's E:'qPtiq Pumrg, LLC_,
Business license number. 3346
❑ Notice of sewage tank non-compliance
Select a8 that apply:
The SSTS has a seepage pit, cesspool, drywell,
leaching pit, or other pit.
C] it has a sewage tank that was designed to be
watertight, but subsequently leaks below the designed
operating depth.
❑ It presents a threat to public safety by reason of
unsecured, damaged, or weak maintenance hole
cover(s) or other unsafe condition.
Designated Certified individual (DCQ Information
Print name: Peter Peterson
Certification number: 9227
I personally conducted the work described above as a Designated Certified Individual of a M nnesota4kensed SSTS Maintenance
Business. t personally conducted the vy procedures to assess the compliance status of each sewage tank in this SSTS:
Designated Certified 05/20/2020
Individuals signature: Date (mmtd ditw): s
www.pca.state.mn.us • 651-296.6300 • 800-657-3864 Use your preferred relay service • Available In rraLtemat �fowm� 3
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