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Property address: 3240 Sixth Ave.N.,Orono,MN Inspector initials/Date: J.O.$/15/18 <br /> 1. Impact on Public Health—Compliance component#1 of 5 <br /> Compiiance criteria: _ Verifieation method(s): <br /> System discharge sewage to the ❑Yes �No � Searched for surtace outlet <br /> �round surface. _ __ � Searched for seeping in yardJbadcup in home <br /> System discharge sewage to drain tile ❑Yes �No ❑ Excessive ponding in soil system/D-boxes <br /> or surface waters. ❑ Homeowner testimony(See Comments/Explanation) <br /> -' ❑ "Bladc soil"above soil dispersal system <br /> System cause sewage backup into I; ❑Yes �No w <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 CommentsiExplanation) <br /> an/mmfnent Threat to Publlc Hea/th and Safety. ❑ Other methods not listed(Ses Comments/Exp�anation) <br /> Com ments/Expla nation: <br /> 2. Tdnk Integrity—Compliance component#2 of 5 <br /> Compliance criteria: Verification method(s): <br /> System consists of a seepage pit, � ❑Yes �No � Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit. � Examined construction records <br /> Seepage pits meeting 7080.2550 may be � ❑ Examined Tank Integrity Form(Attach) <br /> compliant if allowed!n Joca!ordinsnce. I <br /> ❑ Observed liquid level below operating depth <br /> Sewage tank(s)leak befow their ❑Yes � No <br /> designed operating depth. ❑ Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s)leaks: � ❑ Probed outside tank(s)for"black soil" <br /> Any "yes"answer above indicates the � unab�e to verity�see commenrs✓�raaner;o�� <br /> system is Failing to Protect Groundwater. ❑Other methods not listed(See Comments/Explanation) <br /> Comments/Expla nation: <br /> The baffels are in place and the tanks are operating at there designed level. <br /> 3. Other Compliance Condition5—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,�appear to structurally unsound. ❑Yes" �No p UnknoHm <br /> b. Other issues(elechica!hazaros,etc.)to immediately and adversely impact public heafth or safery. ❑Yes� �No ❑Unknown <br /> `System Is an imminent throsaf 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 fafling to pr+�tect groundwater <br /> Explain: <br /> - -- - _ _._.. --- -- <br /> www.pca.state.mn.us • 651•296-6300 • 800•657•3864 • TTY 651-282-5332 or 800•657-3864 • Available in altemative formats <br /> wq-wwists4-31 • 1/24/12 Poge 2 of 3 <br />