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Property address: _160 Truffula Trail.,Orono, MN Inspector initials/Date: J. O.6104/18_ <br /> 1. Impact on Public Health —Compliance component#1 of 5 <br /> Compliance criteria: Verification method(s): <br /> ® Searched for surface outlet <br /> System discharge sewage to the ❑Yes ®No ® Searched for seeping in yard/backup in home <br /> round surface. --- <br /> --- ❑ Excessive ponding in soil system! - oxes <br /> System discharge sewage to drain the ❑Yes ® No ❑ Homeowner testimony(See Comments/Explanation) <br /> or surface waters. _.. _ _—'—_._ ❑ "Black soil"above soil dispersal system <br /> System cause sewage backup into I ❑Yes ® No ❑ System requires"emergency'pumping <br /> dwelling or establishment. _ ❑ Performed dye test <br /> Any"yes"answer above indicates the system is ❑ Unable to verify(See Comment&Explanation) <br /> an Imminent Threat to Public Health and Safety. ❑ Other methods not listed(See Comments/Explanation) <br /> Com ments/Explanation: <br /> 2. Tank Integrity—Compliance component#2 of 5 <br /> Compliance criteria: Verification method(s): <br /> System consists of a seepage pit, ❑Yes ® No <br /> Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit. ® Examined construction records <br /> Seepage pits meeting 7080.2550 may be ❑ Examined Tank Integrity Form (Attach) <br /> compliant if allowed in local ordinance.__ __,_,._,�___.._—___ __ ❑ Observed liquid level below operating depth <br /> Sewage tank(s) leak below their ❑Yes ® No ❑ Examined empty(pumped)tanks(s) <br /> designed operatin depth. _— ❑ Probed outside tank(s)for"black soil" <br /> If yes,which sewage tank(s)leaks: <br /> _____....—.._-----..-_--- ❑ Unable to verify(See CommentwExplanation) <br /> Any"yes"answer above indicates the ®Other methods not listed(See Comments/Explanation) <br /> system is Failing to Protect Groundwater. <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 ❑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 non-protective of ground water for other conditions as determined by inspector ❑Yes* ®No <br /> *System is failing to protect groundwater <br /> Explain: <br /> -- • Available in alternative ormats <br /> wwN.pca.state.mn.us 651-296-6300 800-657-3864 TTY 651 282 5332 or 500 657 3864 page 2 of 3 <br /> wq-wwists4-31 • 1124112 <br /> rage 3 of 3 <br />