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• <br /> Property address: 2245 French Lake Rd,Orono InSpectori tials/Date: JS 17/21/2018 <br /> (mm/dd/yyyy) <br /> 1. Impact on Public Health-Compliance component#1 of 5 <br /> Com•liance criteria: Verification method a): <br /> System discharges sewage to the 0 Yes ®No ®Searched for surfa outlet <br /> round surface. <br /> ®Searched for seeping in yard/backup in home <br /> System discharges sewage to drain 0 Yes ®No 0 Excessive ponding i soil system/D-boxes <br /> tile or surface waters. <br /> 0 Homeowner testimo:y(See Comments/Explanation) <br /> System causes sewage backup into 0 Yes ®No <br /> dwelling or establishment. ❑"Black soil above s•'I dispersal system <br /> 0 System requires"e -rgency"pumping <br /> Any"yes"answer above indicates the ❑Performed dye test <br /> system is an imminent threat to public <br /> health and safety. 0 Unable to verify(See Comments/Explanation) <br /> 0 Other methods not li ted(See Comments/Explanation) <br /> Comments/Explanation: <br /> 2. Tank Integrity—Compliance component#2 of 5 <br /> Com•Hance criteria: Verification method(.): <br /> System consists of a seepage pit, 0 Yes ®No 0 Probed tank(s)botto <br /> cesspool,drywell,or leaching pit. <br /> Seepage pits meeting 7080.2550 may be ®Examined constructi• records <br /> com•liant lfallowed in local ordinance. 0 Examined Tank Integ'ty Form(Attach) <br /> ❑Observed liquid level•elow operating depth <br /> Sewage tank(s)leak below their ❑Yes ®No <br /> designed operating depth. ®Examined empty(pu ped)tanks(s) <br /> If yes,which sewage tank(s)leaks: 0 Probed outside tank(•i for"black soil" <br /> ❑Unable to verify(See •mments/Exp/enation) <br /> Any"yes"answer above indicates the <br /> El methods not lis ed(See Comments/Explanation) <br /> system is failing to protect groundwater. <br /> Comments/Explanation: <br /> 3. Other Compliance Conditions-Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to be structurally un •und. ❑Yes* ®No 0 Unknown <br /> b. Other issues(electrical hazards,etc.)to immediately and adversely impact public health or sat= . 0 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. ❑Yes* ®No <br /> *System is failing to protect groundwater. <br /> Explain: <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864Available in alternative formats <br /> wq-wwists4-31 • 3/16/12 " <br /> Page 2 of 3 <br />