HomeMy WebLinkAbout1840 Fox Street - Septic ComplianceRobert & Angilea McNae
Property address: _ 1840 Fox St _ Parcel l e: 0311723420008
city: Orono state: MN _ zip code:_ 55391
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 (-wwists4-3I b). This form can be
found on the MPCA website at hft2a:lhvww.12ce.state.mn.us/watertsst -and-msts-technical-a!3d-co pliance-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 owners 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.
M Certificate of sewage tank compliance
Affirm all three statements:
The SSTS does not contain a seepage pit, cesspool,
drywell, leaching pit, or other pit.
jSf it does not contain a sewage tank that was designed
to be watertight, but subsequently leaks below the
designed operating depth.
X 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 ail that apply:
The SSTS has a seepage pit, cesspool, drywellp
leaching pit, or other pit.
[] It has a sewage tank that was designed to be
watertight, but subsequently leaks below the designed
operating depth.
d 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: 3346Certification 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 n ary procedures to assess the compliance status of each sewage tank in this SSTS:
Designated Certified 09/11 /2023
Individual's signature: Date (mm/dd/yyyy): --
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