HomeMy WebLinkAbout05-19-2020 Septic Compliance Cert.Mike Gualtieri & Shawna Johnson parcel ID: 04-117-23-12-N17
Property address: 2755 Countryside Drive West _ _ �_ _
State _MN �p code: 55356 ..
City Orono _ �..
optional section: Sewage Tank Compliance Certification
This form does not represent a complete system inspection report and only aerafles sewage tank compllance status.
dual
Instructions: This ss wh of the form may be
the necessnarrysprn�dures to assess the compliancted Certified e status ofleach sewage tan kin
Maintenance Business who personally Gond
the system. docurnantallon to an
When this section ofthe form Is signed by a qualified certified profeaslonai, it becomes necessary aupAor#int7 . This farm can be
Existing System Compliance Inspection Report 11 ec
found on the MPCA webalte at
The Information and certified statement on this form is inquired when existing septic tank compliances status
Isment r dined by an
Individual other than the SSTS inspector that submits the inspection report. It represents a third party
SSTS
component compliance and is allowable under Minn. R. 7082.070(1, subp. 4 ltion is eat (B) subitem (1). This form Is valid for a period of
three require years beyond rgthe signature regulations. date on this form unless a new Additions Administrative Rue references for theirs by
can be found at the owner or owner'sM nit or Is
required according to local
n.
R. 7082.0700, subp. 4 Items B, C, and 0; 7083.0730 Item C.
)ffi of ❑ Notice of sewage tank non-compliance
Certifies#e sewage tank compliance
Affirm all three statements: Select all that apply=
D4 The SSTs does not contain a seepage pit, cesspool,
't '
drywell, leaching pit, or other pit.
$t It does contain a sewage tank that was designed
to be watertight, but subsequently leaks below the
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
❑ The SSTS has a seepage pr cesspool drywall,
,
leaching pit, or other pit,
It has a sewage tank that was designed to be
watertight, but subsequently leaks below the designed
7jtprresennt8dTt'hh�-9t to public safety by reason ofecured, damaged, or weak meintenar" hose
cover(s) or other unsafe condition.
Designated Certified individual (DCI) infotmatlon
Company natter: Allen's Se 'c��_�______ �.:.
Print name: Peter Peterson _—
Business license number: 3348 Certification number. R27
1 pe►satallY cortducted the work described above as to assesnated s thcomplianceIndividual �tatusr of each sewage lank, in � sr SSTs:
Business. J Personally conducted the n ry procedures
Designated Certified Date (mm/ddlyyyy): _ 05/1912020
individuars signature:
.._
Available in attemativc formats
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