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' Property address: 465 Spring Hill,Orono,MN ___ __ Inspector initials/Date: J.O.9/07/18 <br /> 1. ImpaCt on Publit Health—Compliance component#1 of 5 <br /> Compliance criteria: � Verification method(s): <br /> System discharge sewage to the j ❑Yes � No � Searched for surface outlet <br /> ground surface. � Searched for seeping in yard/badcup in home <br /> System discharge sewage to drain tile fi�Yes �No ❑ Excessive ponding in soil system/D-boxes <br /> or surface waters. ❑ Homeowner testimony(See Comments/Explanation) <br /> System cause sewage backup into ❑Yes �No � �Bladc soil"above soil dispersal system <br /> dwelling or establishment. � ❑ System requires"emergenc�l'pumping <br /> Any"yes"answer above indicates the system is � Performed dye test <br /> ❑ Unable to verify(See CommentsiExplanation) <br /> an/mminent Threat to Public Health and Safety. ❑ Other methods not listed(See Comments/Explanation) <br /> Comments/Explanation: <br /> 2. Tank Integrity—Compliance component#2 of 5 <br /> Compliance criteria: Verlfication method(s): <br /> System consists of a seepage pit, r�Yes �No ❑ Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit. <br /> � Examined construction records <br /> Seepage pits maeting 7080.2550 may be ❑ Examined Tank Integrity Form(Attach) <br /> compliant if allowed in local ordinance. <br /> � ❑ Observed liquid level below operating depth <br /> Sewage tank{s)leak below their �' p Yes �No � Examined empty(pumped)tanks(s) <br /> designed operating depth. <br /> If yes,which sewage tank(s)leaks: � ' ❑ Probed outside tank(s)for"black soil" <br /> Any "yes"answer above indicates the ❑ Unable to verify(See CommentsJExplanation) <br /> system is Fallfng to Protect Groundwater. �Other methods not listed(See Comments/Explanation) <br /> Comments/Explanation: <br /> The tanks are operating at there normal level and the baffels are in place. <br /> 3. Other Compliance Conditions—Compliance component#3 of 5 <br /> a. Mairrtenance hole covers are dama9ed,cracked,unsecured,or appear to structurally unsound. ❑Yes• �No ❑Unknoam <br /> b. Other issues(ele�tricer hazarols,etc.)to immediately and adversely impad public heatth or safety. ❑Yes' �No 0 Unknown <br /> *System is an lmminent threat fo�blic heaftl�and safety <br /> Explain: <br /> c. System is non-protective of ground water for other conditions as detertr�ined by inspector ❑Yes• �No <br /> "System!s fafling to probect groundwate� <br /> Explain: <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 . f/24/7Z Page 2 of 3 <br />