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4720 North Arm Dr,Orono Mn 55364 <br /> Property address: Robbert Innes Inspector initials/Date: LB 618 <br /> 1. Impact on Public Health-Compliance component#1 of 5 <br /> Com•fiance criteria: Verification method(s): <br /> System discharge sewage to the Yes ❑No 0 Searched for surface outlet <br /> round surface. ❑ Searched for seeping in <br /> P 9 yard/backup in home <br /> System discharge sewage to drain tide 0 Yes 0 No ❑ Excessive ponding in soil systemiD•boxes <br /> or surface waters. 0 Homeowner testimony(See Comment <br /> s/Explanation) <br /> System cause sewage backup into 0 Yes 0 No ❑ 'Black soil'above soil dispersal system <br /> dwelling or establishment. ❑ System requires"emergency'pumping <br /> Any"yes"answer above Indicates the system Is ❑ Performed dye test <br /> ❑ Unable to verify(See Commentsgxptanatian) <br /> an Imminent Threat to Public Health and Safety. <br /> 0 Other methods not listed(See Comments/Explanation) <br /> Comments/Explanation: <br /> 2. Tank Integrity-Compliance component#2 of 5 <br /> Corn'fiance criteria: Verification method(s): <br /> System consists of a seepage pit, 0 Yes ,lo ❑ Probed tank(s)bottom <br /> cesspool,drywall,or leaching pit. <br /> ❑ Examined construction records <br /> Seepage pits meeting 7080.2550 may be <br /> com..': t d allowed in local ordinance. ❑ Examined Tank Integrity Form(Attach) <br /> Sewage tank(s)leak below their <br /> 0 Observed liquid level below operating depth <br /> des!.ned o••>ratin. de.th. Yes Flo ® Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s)leaks: <br /> /� ❑ Probed outside tank(s)for'blade soil' <br /> Unable to verify(See commenls/Exprenarion) <br /> Any"yes"answer above indicates the <br /> Other methods not fisted(See Comments/Explanation) <br /> system is Failing to Protect Groundwater. <br /> Comments/Explanation: <br /> Compliant per 7080 Code: 0/ No <br /> Notes: ,3-/0o 9a!(e,„ -/z„/r 4" r F rt' )w o ` 4,dc S art /eJ.e, b <br /> Business Name: Kothrade Sewer,Water,Excavating,Inc 4 �r+ (11^4c4; �� <br /> 1 p{ <br /> Business Address: 12059 Whitetail Ln,Hanover MN 55341 • <br /> N� C 6S•Prv� <br /> Business Phone: 763.498.8702 <br /> Company Representative: Lary 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 ❑Unknown <br /> b. Other issues(electrical hazards etc.)to immediately and adversely impact public health or safety. ❑Yes* 0 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 0 Yes* ❑No <br /> 'System Is failing to protect groundwater <br /> w+yw.ixa.state.mn.us • 651-296-6300 • 800.657-3864 <br /> • <br /> we-wwlsts4-31 • 1/24/12 TTS'651.282-5332 or 800-657-3864 • Available In alternative formats <br /> Page 2 of 4 <br />