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Jan 28 2016 07:04PM HP FaxRusty Olson 7634988290 page 3 <br /> Property address: 2575 Thoroughbred Lane Orono MN <br /> Inspector initials/Date: J.0. 1/27/16 <br /> I. Impact on Public Health—Cornpliance component#1 of 5 <br /> Compliance criteria: Verification method(s): <br /> System discharge sewage to the ❑Yes ®No ® Searched for surface outlet <br /> round surface- <br /> ® Searched for seeping in yardJbackup 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 Comrnents/Exptanatlon) <br /> System cause sewage backup into ❑Yes ®No ❑ "Black Boll'above soil tlispersal system <br /> dwelling or establishment ❑ System requires"emergency"pumping <br /> Any"yes"answer above Indicates the system is ❑ Performed dye test <br /> an Imminent Threat to Public Health and Safety. ❑ Unable to verity(See CammentvExtuanation) <br /> Comments/Explanation: ElOther methods not listed(See Comments/Explenatron) <br /> 2. Tank Integrity—Compliance component#2 of 5 <br /> Com liance criteria: Verification method(s): <br /> System consists of a seepage pit. ❑Yes ®No ® Probed tank(s)bottom <br /> cesspool,drywall,or leaching pit. <br /> Seepage pits meeting 7080.2550 maybe ® Examined construction records <br /> compliant 9 alknved in total ordinance ❑ Examined Tank Integrity Form(Attach) <br /> Sewage tank(s)leak below the!r103 Observed liquid level below operating depth <br /> designed operating depth. ❑Yes ®No ❑ Examined empty(pumped)tanks(s) <br /> If yes,which sewage tanks)leaks: ❑ Probed outside tank(s)for"black soil" <br /> ElUnable to verify(See commentwExplanatton) <br /> Any"yes"answer above indicates the <br /> system is Failing to Protect Groundwater. ®Other methods not listed(See comment&Exptanation) <br /> Co mmen ts/Explanati o n: <br /> Alban septic Company varified the tanks <br /> 3" Other Compliance Conditions—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to structurally unsound. []yea* O No ❑unknown, <br /> b. Other issues(etecbkWhazards,etc.)to immediately and adversely impact pubic health or safety. ❑Yes• ONO ❑Unknown <br /> 'SY810M is an Imminent threat to public health and safety <br /> Explain: <br /> c. System is non-protective of ground water for other condition as determined by inspector ❑yes* ®No <br /> 'System is falling to protect groundwater <br /> Explain: <br /> www.pca.state.mn.us 651-296-6300 800-657-3864i <br /> wq-ww/sts4-31 • 1/24112 TTY 651 282 5332 or 800.657-3864 Available in alterative formats <br /> Page 2of3 <br />