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Nov ZO 2015 0727PM HP FascFiusty Olson 7634988290 page 3 <br /> Property address: 1980 Sixth Ave. N Orono MN Inspedor Initials/Date: J. 0.11/30/15 <br /> 1. ImpdCt on PubliC Hedlth—Cornpliance component#1 of 5 <br /> Compliance criterla: Verification msthod(s): <br /> r <br /> System discharge sewage to the ' ❑Yes �No � �arched for surface ouilet <br /> ground surface. � Searched for seeping in yardlbadcup in home <br /> System dischar�ge sewage to drain tlle � ❑Yes � No � ��sive ponding in soil systemlD-boxes <br /> or surfac;e waters. I ❑ Homeowner testimony (See Cvmments/ExaanaGon) <br /> ❑ "Black soil"above sal dispersal system <br /> System cause sew2ge backup into ❑Yes �No ❑ System requires"emergency"pumping <br /> dwefling or establishment. ❑ Perforrned dye test <br /> Any'�yes"answer above indicates the sysfem is ❑ Unable to verify�see Commenrsgxpranadon) <br /> an!mm/nent Threst to Public Health and Safety. ❑ p��meihods not listed(See Commerrts�expranetion) <br /> CommentslExplanation: <br /> 2. Tenk I�tegr'1ty—Complia�ce component#2 of 5 <br /> Com liance criteria: Verffication method(s): <br /> Sysiem cansists of a seepage pit, ❑Yes �No ❑ Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit. j <br /> ❑ Examined construdion records <br /> Seepege pits meetrrrig 7080.255o maybe i ❑ Exarnined Tank Integrity Form(Atfach) <br /> corn ianf il allour�d in/oca!wdinance. <br /> Se�va e tank s leak below their ❑ ��eroed liquld level below operating depth <br /> 9 � ) i ❑Yss �No ❑ Examined emply(pumped)tanks(s) <br /> desi rted o tin de th. <br /> If yes,which sewage tank(s)leaks: ❑ Probed outside tank(s)for"bladc soil" <br /> ❑ Unable fo veriTy(See canments/Explanation) <br /> Any"yes"snswer above inalicates the �p1her methods not lisled(See Comments/Exp�anation) <br /> system is Failinq to Protect Groundwater. <br /> Co m mentslExplan ation: <br /> See tank report <br /> 3. Other Comptiance Conditions—Compliance component#3 of 5 <br /> a. Malntenance hole covers are damaged,cracked, unsecured,or appear to strudurally unsound. ❑Yas* �No ❑Urrcnown <br /> b. Other issues(efectrreslhazaros,etc.)to immediately and adv�ersely impacl pubNc heslth or satety. p Yes* �No ❑Unknown <br /> 'Sys(em Js an fmminent thivat to public health and satety <br /> Explain: <br /> c. System is non-protective of ground water for other conditions as determined by inspedor ❑Yes* �No <br /> 'System is fa1!!nq ta protectgr�nundwater <br /> Explain: <br /> www.pca.state.mn.us • 651-29b-6300 • 800-657•3864 • TTY 651•282•5332 or 500-657-3864 . Available in alcernaiive formats <br /> wq-wwists4•3f • fl24/f2 Paqe 2 of 3 <br />