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Property address: 1235 Lyman Ave, Orono Inspector initials/Date: JS 14/25/2018 <br /> (mm/dd/yyyy) <br /> 1. Impact on Public Health — Compliance component#1 of 5 <br /> Compliance criteria: Verification method(s): <br /> System discharges sewage to the ❑Yes ® No ® Searched for surface outlet <br /> ground surface. i Searched for seeping inyard/backup in home <br /> System discharges sewage to drain ❑Yes ® No ❑ Excessive ponding in soil system/D-boxes <br /> tile or surface waters. <br /> ❑ Homeowner testimony(See Comments/Explanation) <br /> System causes sewage backup into ❑ Yes ® No ❑ "Black soil"above soil dispersal system <br /> dwelling or establishment. i <br /> — ❑ System requires"emergency"pumping <br /> Any"yes"answer above indicates the ❑ Performed dye test <br /> system is an imminent threat to public ❑ Unable to verify(See Comments/Explanation) <br /> health and safety. <br /> ❑ Other methods not listed(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, ❑Yes ® No 0 Probed tank(s)bottom <br /> cesspool, drywell, or leaching pit. <br /> ® Examined construction records <br /> Seepage pits meeting 7080.2550 maybe j ❑ Examined Tank Integrity Form (Attach) <br /> compliant if allowed in local ordinance. <br /> Sewage tank(s)leak below their ❑ Observed liquid level below operating depth <br /> ❑Yes ® No <br /> designed operating depth. ® Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s) leaks: j ❑ Probed outside tank(s)for"black soil" <br /> Any "yes"answer above indicates the El Unable to verify(See Comments/Explanation) <br /> system is failing to protect groundwater. ❑ Other methods not listed(See Comments/Explanation) <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 unsound. 0 Yes* ®No ❑Unknown <br /> b. Other issues(electrical hazards,etc.)to immediately and adversely impact public health or safety. ❑Yes* Z 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 /> Explain: <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats <br /> wq-wwists4-31 • 3/16/12 Page 1 of 3 <br />