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r' a Property address: 1540 Sixth Ave N,Orono, MN 55356 _ Inspector initials/Date:��10/22/2016 _ � (mMdd/yyyy) 1. Impact on Pubtic Health—Compliance component#1 of 5 Compliance criteria: Verification method(s): System discharges sewage to the ❑Yes � No �Searched for surface outlet ground surface. ____ ____ � Searched for seeping in yard/badcup in home System discharges sewage to drain ❑Yes �No ❑ Excessive ponding in soil system/D-boxes tile or surface waters. ❑ Homeowner testimony(See Comments/Explanation) System causes sewage backup into ❑Yes �No ❑"Bladc soil"above soil dispersal system dwelling or establishment. _ _ ❑ System requires"emergency"pumping Any"yes"answer above indicates the ❑ Performed dye test system is an imminent threat to publlc ❑ Unable to verity(See Comments/Explanation) hea/th and safety. ❑Other methods not listed(See Comments/Explanation) Comments/Explanation: Ran pump to determine hydraulic loading and found no issues 2. Tank Integrity—Compliance component#2 of 5 Com liance crlterla: Verification method(s): System consists of a seepage pit, ❑Yes � No ❑ Probed tank(s)bottom cesspool,drywell,or leaching pit. �Examined construction records Seepege pits meeting 7080.2550 may be ❑ Examined Tank Integrity Form(Attach) compliant if allowed in bcal ordinance. ❑Observed liquid level below operating depth Sewage tank(s)leak below their ❑Yes �No designed operating depth. �Examined empty(pumped)tanks(s) If yes,which sewage tank(s)leaks: �Probed outside tank(s)for"black soil" A/!)/ "yes"answer above indicates the ❑ Unable to verify(See Comments/Explanation) system is failing to protect groundwater. ❑Other methods not Ifsted(See Comments/Explanation) Com ments/Explanation: .Tanks were pumped at time of inspection. 3. Othe�COmplianCe Conditlons—Compliance component#3 of 5 a. Maintenance hole covers are damaged,cracked,unsecured,or appear to be structurally unsound. ❑Yes" �No ❑Unknorvn b. Other issues(electrical hazards,etc.)to immediately and adversely impad public heafth or safety. ❑Yes" �No ❑Unknown 'System is an im►ninent threat to public health and safety. Explain: c. System is non-protedive of ground water for other conditions as deteRnined by inspedor. p Yes• �No "System Is failing to protect groundwater. Explain: — ---- —---- --- ------ -- — --- www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TT`!651-282-5332 or 800-657-3864 • Available in atternative formats wq-wwfsts4-31 • 3/16/12 Page 2 of 3