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Property address: 2650 Countryside Drive W, Orono, MN Inspector initials/Date: J. 0. 5/22/19 <br /> 1 . Impact on Public Health—Compliance component#1 of 5 <br /> Compliance criteria: Verification method(s): <br /> System discharge sewage to the 0 Yes ® No ® Searched for surface outlet <br /> ground surface. ® Searched for seeping in yard/backup in home <br /> System discharge sewage to drain tile 0 Yes ® No ❑ Excessive ponding in soil system/D-boxes <br /> or surface waters. 0 Homeowner testimony(See Comments/Explanation) <br /> System cause sewage backup ❑ "Black soil"above soil dispersal system <br /> Y g into0 Yes ® No 0 System requires"emergency" pumping <br /> dwelling or establishment. <br /> 0 Performed dye test <br /> Any"yes"answer above indicates the system is 0 Unable to verify(See Comments/Explanation) <br /> an Imminent 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: Verification method(s): <br /> System consists of a seepage pit, 0 Yes ® No ❑ Probed tank(s) bottom <br /> cesspool, drywell, or leaching pit. ❑ Examined construction records <br /> Seepage pits meeting 7080.2550 maybe 0 Examined Tank Integrity Form (Attach) <br /> compliant if allowed in local ordinance. <br /> 0 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 /> Any "yes"answer above indicates the <br /> 0 Unable to verify(See Comments/Explanation) <br /> system is Failing to Protect Groundwater. ® Other methods not listed (See Comments/Explanation) <br /> Comments/Explanation: <br /> Elmer J. Peterson Company pumped 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. ❑Yes* ®No 0 Unknown <br /> b. Other issues(electrical hazards,etc.)to immediately and adversely impact public health or safety. ❑Yes* ®No 0 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• El No <br /> *System is failing to protect groundwater <br /> Explain: <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 • 1/24/12 <br /> Page 2 of 3 <br />