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990 N Shore Dr W,Orono Mn 55356 <br /> Property address: Jason Wilsey Inspector initials/Late: LB 6-11-18 <br /> 1. Impact on Public Health-Compliance component#1 of 5 <br /> Compliance criteria: Verification method(s): <br /> System discharge sewage to the ®Yes ❑ No 0 Searched for surface o:itlet <br /> •round surface. 0 Searched for seeping H yard/backup in home <br /> System discharge sewage to drain tile ❑Yes 0 No ❑ Excessive ponding in soil system/D-boxes <br /> or surface waters. ❑ Homeowner testimony(See Comments/Explanation) <br /> System cause sewage backup into 0 Yes 0 No ❑ "Black soil"above soil dispersal system <br /> System <br /> ling or elishment. ❑ System requires"emergency"pumping <br /> dw -- --- .❑ Performed dye test <br /> Any"yes"answer above indicates the system Is 0 Unable to verify(See C.-nments/Explanation) <br /> an Imminent Threat to Public Health and Safety. 0 Other methods not list,::(See Comments/Explanation) <br /> Comments/Explanation: <br /> 2. Tank Integrity-Compliance component#2 of 5 <br /> Compliance criteria: Verification method(s): <br /> System consists of a seepage pit, 0 Yes giNo 0 Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit. 0 Examined construction records <br /> Seepage pits meeting 7080.2550 may be ❑ Examined Tank Integrr.• Form(Attach) <br /> compliant if allowed in local ordinance. <br /> 0 Observed liquid level below operating depth <br /> Sewage tank(s)leak below their 0 Yes plo <br /> designed operating depth. ® 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 ❑ Unable to verify(See Conments/Explanation) <br /> system is Failing to Protect Groundwater. ❑ Other methods not lists=: (See Comments/Explanation) <br /> Comments/Explanation: <br /> Compliant per 7080 Code: ag, No <br /> Notes: 427425O /— <br /> Business Name: Kothrade Sewer,Water,Excavating,Inc <br /> Business Address: 12059 Whitetail Ln, Hanover MN 55341 <br /> Business Phone: 763.498.87021 <br /> Company Representative: Larry Bursch MPCA#: 0192/9199 Signature L 167—11 <br /> _l <br /> 3. Other Compliance Conditions-Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to structurally unsound Ives* ❑No ❑Unknown <br /> b. Other issues(electrical hazards,etc.)to immediately and adversely impact public health or safety. " ,Yes" ❑No 0 Unknown <br /> *System is 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 L: Y • ❑No <br /> *System is failing to protect groundwater <br /> www.pca.state.mn.us • 651-296-6300 v 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • .wailabte in attemative formats <br /> wq-wwists4.31 • 1/24/12 Page 2 of 4 <br />