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May 22 13 08:55a Joseph Olson 763-498-8290 p.3 <br /> Property address: 2425 Throughbred Lane Orono MN Inspector initials/Date: J. 0.05120M3 <br /> 1. Impact on Public 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 /> round surface. ® Searched for seeping in yard/backup in home <br /> System discharge sewage to drain file [:]Yes ®No ❑ Excessive ponding in soil system/D-boxes <br /> or surface waters. ❑ Homeowner testimony(see Commerns(F.xp/anaum) <br /> ❑ "Black soil'above soil dispersal system <br /> System cause sewage backup into [--]Yes ®No ❑ System requires'emergency'pumping <br /> dwelling or establishment <br /> ❑ Performed dye test <br /> Any"yes"answer above indicates the system is <br /> an Imminent Threat to Public Health and Safety. ❑ Unable to verify(see CommentslExplanaSon) <br /> ❑ Other methods not listed(See CommentslExplanation) <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. ® Examined construction records <br /> Seepage pits rneeft 7080.2550 may be ❑ Examined Tank Integrity Form(Attach) <br /> cornpAW if Mowed in local ordinance. <br /> ❑ Observed liquid level below operating depth <br /> Sewage tank(s)leak below their El Yes 0 No <br /> designed operating depth. ❑ Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s)leaks: ❑ Probed outside tank(s)for"black soir <br /> Any`Yes"answer above indicates the ❑ Unable to verify(Sea CommentwExplanation) <br /> system is Failing to Protect Groundwater. ❑Other methods not listed(See Commentv&p/anation) <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 structurally unsound. ❑Yes' ®No ❑Unknown <br /> b. Other issues(electrical hazards etc.)to immediately and adversely impact public health or safety. ❑Yes' ®No ❑Unknown <br /> 'System is an imminent threat to public health and safety <br /> Explain: <br /> c. System is nonprotective of ground water for other conditions as determined by inspector ❑Yes` ®No <br /> "System is failing to protect groundwater <br /> Explain: <br /> www.pca.state.mn.us • 651-296-6340 • a00.657-3864 TTY 651-282-5332 or 800-657.3864 Availabte in altemative formats <br /> wq-ww1sts4-31 • 1124112 Page 2 of 3 <br />