HomeMy WebLinkAbout08/15/2022 Septic Maintenance Report2022 SEPTIC MAINTENANCE REPORT
Site address: 2790 White Oak Circle Nicholas & Suzanne Hansen
Nusmber of tanks: 3 Date last pumped: 08/15/2022 Gallons pumped: 2700
Name of pumper/ maintenance provider: Albin's Septic Pumping, LLC
Are tanks watertight?:
Is the system functioning properly?
VAC
YES IVO
(please circle one)
(ie slow drainage, wetness in the drainfield?)
Do you have any specific concerns or issues that you'd like to discuss with the SSTS Program Manager?
Note: Recommend filiing tanks back to operating level to revent movement during winter/s ring
frost as home is being demolished and a new home built by Norton Homes, LLC.
if so, please indicate best time and telephone number(s) to be reached between 8 am and 4:30 pm.
Best Times
Alicia Johnson
CITY OF ORONO
PO BOX 66
CRYSTAL BAY MN
Telephone Number(s)
RETURN IN THE ENCLOSED ENVELOPE
AS SOON AS POSSIBLE
55323-0066
Property address: 2790 White Oak Circle (Nicholas & Suzanne Hansen) Parcel ID: 0411723420016
City: Orono State: MN _ zip code: 55356
Optional section: Sewage Tank Compliance Certification
This form does not represent a complete system inspection report and only certifies sewage tank compliance status.
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 LM-wwists4=31 b1. This form can be
found on the MPGA website at h ./Awww.pca.state.mn.us/waterlasts-and-msts-technical-and-comoliance-cnteria.
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 subr its 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 Item C.
I& 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 not 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.
❑ Notice of sewage tank non-compliance
Select all that apply:
❑ The SSTS has a seepage pit, cesspool, drywell,
leaching pit, or other pit.
❑ 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.
Company Information Designated Certified Individual (DCI) Information
Company name: Aibin's Septic -Pumping, LLC Print name: Peter Peterson
Business license number: 3346 Certification number: 9227
I personally conducted the work described above as a .Designated Certified individual of a Minnesota -licensed SSTS Maintenance
Business. I personally conducted the necusary procedures to assess the compllance status of each sewage tank in this SSTS:
Designated Certified 08/15/2022
Individual's signature: _ Date (mm/ddNyyy):
www.pca.state.mn.us • 651-296-6300 800.657-3864 use your preferred relay service • Available in alternative formats
wq-wwists4-38 • 1127117 Page 3 of 3