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Peter Scherer <br /> Property address: 15 Orono Orchard Rd S.Orono MN 55391 Inspector initials/Date: LB 9-11 -18 <br /> 1. Impact on Public Health—Compliance component#1 of 5 <br /> Corn'Hance criteria: Verification method(s): <br /> System discharge sewage to the 0 Yes 0 No 0 Searched for surface outlet <br /> •round surface. 0 Searched for seeping in yard/backup in home <br /> System discharge sewage to drain tile 0 Yes ❑No ❑ Excessive ponding in soil systemlD-boxes <br /> or surface waters. 0 Homeowner testimony(See Comments/Explanation) <br /> System cause sewage backup into ❑Yes ❑No ❑ "Black soil`above soil dispersal system <br /> dwelling or establishment. © System requires"emergency"pumping <br /> 0 Performed dye test <br /> Any"yes"answer above indicates the system is 0 Unable to verify(See Comments/Explanar/on) <br /> en imminent Threat to Public Health and Safety. 0 Other methods not listed(See Comments/Explanation) <br /> Comments/Explanation: <br /> 2. Tank Integrity—Compliance component#2 of 5 <br /> Corn•liance criteria: Verification method(s): <br /> System consists of a seepage pit, ❑Yes 'lo 0 Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit. <br /> ❑ Examined construction records <br /> Seepage pits meeting 7080.2550 may be ❑ Examined Tank Integrity Form(Attach) <br /> •lent if allowed in local ordinance. <br /> Sewage tank(s)leak below their El Yes o ❑ Observed liquid level below operating depth <br /> des•ned o•=ratin, death. >=< Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s)leaks: ❑ Probed outside tank(s)for"black soil" <br /> Any"yes"answer above indicates the CI Unable to verify(See Comments/Explanation) <br /> system is Failing to Protect Groundwater. ❑Other methods not listed(See Comments/Explanation) <br /> Comments/Explanation: <br /> Compliant per 7080 Code No <br /> Notes: 1 —1 Alp p2—loin 9. tioA_l I sait�S <br /> Business Name: Kothrade Sewer,Water,Excavating,Inc <br /> Business Address: 12059 Whitetail Ln,Hanover MN 55341 <br /> Business Phone: 763.498.8702 <br /> Company Representative: Larry Bursch MPCA#: 0192/9199 Signature <br /> 3. Other Compliance Conditions—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to structurally unsound. 0 Yes* 0 No 0 Unknown <br /> b. Other issues(electrical hazards,etc.)to immediately and adversely impact public health or safety. El Yes* 0 No 0 Unknown <br /> *System Ls an imminent threat to public health and safety <br /> Explain: <br /> c. System is non-protective of ground water for other conditions as determined by inspector 0 Yes* 0 No <br /> *System Is failing to protect groundwater <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282.5332 or 800-657-3864 • Available in alternative formats <br /> wq-wwists4-31 • 1/24/12 <br /> Page2of4 <br />