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Ju111 1212:04p Joseph Olson 763-498-8290 p.2 <br /> � Minnesota Potiution Compliance Inspection Form <br /> tontrol Agency <br /> 520 Lafayette Road Norifi ��Sw�9 Subsurfa�e Sewage Treatme�! Systen�s <br /> St Paut,MI�55155-4194 ��g'rg� <br /> Doc Type:Complfance and E�+oroement <br /> lnstructions: Inspec�ion res�Es based on Minnesota Polluhion Contral Aeency(MPCA) For local tradcing purposes: <br /> requireme�s and attacF�ed fiorms-addi�onal local requir�emeMs rrray also appfy. <br /> Subrnit ccmpleted fomi to Local U�t of Gavemment(LUG)and sysbern owner <br /> within 15 days <br /> System Status <br /> System stabus on datie(mm/ddlYYyy): TH 112012 <br /> � Compliant-Certificate of Compliance ❑ Noncompliarrt- Notice of Noncompliance <br /> (Valid for 3 ysais fiam nepaf dafe, ui►less shorter frme (See Upgrade Requirvmer�ts or�page 31 <br /> frame outlined in Loca1 Oidinance.) <br /> Reasa��s)br noncomplias�ce{check a!/applicabJe) <br /> ❑ ImRact on Public Health (Compiiaace Component #9)-Imminer�t tirreat fo public hea�th and safeiy <br /> ❑Other Compliance Conditions(Compliance Component iR?)-Imrninent tfr�at to pubfic health and saffety <br /> ❑Tank Integrity(CcxnpGance Component #2)-Failirrg to protect groundwater <br /> ❑other C�nplisrece Condfions(Compliance Component�l3)-Faihng to protect giaundwater <br /> Q Soil Separation(Compliance Componerrt #4)-Fai!'urg to protecf groundweter <br /> ❑OperaGng permiUmonit�ing plan requi�rnents(Compliance Co�ponent #�-IVor�compliant <br /> Praperty Infomnation Parc�l ID#or SecJTwp/Range: 211 1 62 341 0003 <br /> Property address: �749 North Farm Road.,Orono, MN Reason tor inspedion: Property Transfer <br /> Property owner. Jeffrey&Jodelle Quiram Owner's phone: 612-689-4306 <br /> or <br /> Owner's represe►rtat2ve: Representalive phone: <br /> Lacal regulatory authosity: City of Orono Regulatory authority phone: 952 249-4600 <br /> 2-1000 gallon septic tanks,l-1000 galbn EiR station and 680 square ff�oi mound rockbed.per city <br /> Brief system descriptior�: recwds <br /> Comrttenis w recommendatians: <br /> Certification <br /> I hereby cert�fy that al!fhe neoessary inlaimation has been gathered to de�ermine ti►e complian�ce sfatus of this system.No <br /> detemrinatFon of future sysGem perforrr�ar�ce has bee»nor can be made due in anlmown conditions during system const�on, <br /> possJWe abuse of t�e system,inadequate mainfe�enoe, or futu�e wate�usage. <br /> Inspedor narne: Joseph J Olson Certficafion number. 1255 <br /> 6usiness name: Ru O on's Soil 8�Perc.Testin license number: 810 <br /> Inspedor signature: Phone number: 763-498-6779 <br /> Necessary or Locally Required Attac�ments <br /> �Soil boring fogs �System/As-built drawing ❑ Forms per local ordinance <br /> �Oiher informalion(list): <br /> www.pca.state.mn.us • 651-296•63U0 • 600-667-3864 • TTY 651-Z82-5332 or 800-657-3864 • Available in attemative formats <br />