HomeMy WebLinkAbout5-18-2023 septic compliance inspectonOrono PID# 2711823320009
David & Michelle Denniston Medina PID# 2711823230002
Property address; 1200 Phillips Drive Parcel ID: _-
city: Orono - Medina __. 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 SETS
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-wwists!L-31 bt. This form can be
found on the MPCA website at https:ltww J.pca state mn ustwaterfssts-and,-msts-technical-and-compliance-criteria.
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 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.
® Certificate of sewage tank compliance
Affirm all three statements:
The SSTS does not contain a seepage pit, cesspool,
dryweil, leaching pit, or other pit.
$( it does riot contain a sewage tank that was designed
to be watertight, but subsequently leaks below the
designed operating depth.
®
11 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: Albin's Septic Pumping, LLC
Business license number: 3346
❑ 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.
Designated Certified Individual (DCI) information
Print name: Peter Peterson _
Certification number. 9227
I personally conducted the work described above as a Designated Certified Individual of a Minnesota -licensed SSTS Maintenance
Business. l personalty conducted the n ry procedures to assess the compliance status of each sewage tank in this SSTS:
Designated Certified
Individual's signature: _ Date (mmlddlyyyy): _05/18/2023_.
www.pca.state.mn.us • 651-246-6300 800-657-3864 Use your preferred relay service Available in attemative formats
wq-ww1sts4.38 • 1127117 Page 3 of 3