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� <br /> Property address: 4225 County Road 6 Orono Inspector initials/Date: ___ 1 __ ____ <br /> ---- _-- _ _._.—____ __ <br /> (mMdd/yyyy) <br /> 1. Impact on Public Health —Compliance component#1 of 5 <br /> Compliance criteria: Verification method�s): <br /> __ -- _--- <br /> System discharges sewage to the ❑Yes � No � Searched for surface outlet <br /> ground surface. ________ ___i _ � Searched for seeping in yard/backup in home <br /> ------- --- <br /> System discharges sewage to drain � ❑Yes � No ❑ Excessive ponding in soil system/D-boxes <br /> tile or surface waters. <br /> --------- -- .----- - .---- ❑ Homeownertestimony(SeeComments/Explanetion) <br /> System causes sewage backup into ' ❑Yes � No �"Black soil"above soil dispersal system <br /> dwelling or establishment. <br /> --- ------- ---- ---- - ❑ System requires"emergency"pumping <br /> Any"yes"answer above indicates the ❑ Performed dye test <br /> system is an imminenf threat to public <br /> hea/th and safety. ❑ Unable to verify(See Comments/Explanation) <br /> ❑ Other methods not listed(See CommentsiExplanation) <br /> Com mentslExplanation: <br /> 2. Tank 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. ' <br /> � Examined construction records <br /> Seepage pits meeting 7080.2550 may be ❑ Examined Tank Integrity Form(Attach) <br /> comPliant if allowed in local ordinance. <br /> _ _ _ _____ ___--- <br /> — Observed liquid level below operating depth <br /> Sewage tank(s)leak below 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 /> --- _-- _ ._ --- __ <br /> Any"yes"answer above indicates !he ❑ Unable to verify(See CommentsiExp/anation) <br /> system is failing to protect groundwater. ❑Other methods not listed(See Comments/Expfanation) <br /> Comments/Explanation: <br /> 3. Othe�COmplia�Ce COnditlOns—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to be structurally unsound. ❑Yes" �No ❑Unknown <br /> b. Other issues(electrical hazards,etc.)to immediately and adversely impact public health or safety. p Yes' �No ❑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 /> --- __ _ _- - ------ -- __. — <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 2 of 3 <br />