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Property address: 465 Tumham Road Orono,MN.55359 Inspector initials/Date: I April 20,201 <br /> (mm/dd/yyyy) <br /> 1. Impact on Public Health—Compliance component#1 of 5 <br /> Compliance criteria: Verification method(s): <br /> System discharges sewage to the ❑Yes ®No ®Searched for surface outlet <br /> round surface. ®Searched for seeping in yard/backup in home <br /> System discharges sewage to drain ❑Yes ® No ❑ Excessive ponding in soil system/D-boxes <br /> tile or surface waters. ❑Homeowner testimony(See Comments/Explanation) <br /> System causes sewage backup into ❑Yes ® No ❑"Black soil"above soil dispersal system <br /> dwelling or establishment. 1 ❑ System requires"emergency'pumping <br /> Any"yes"answer above indicates the ❑Performed dye test <br /> system is an imminent threat to public ❑Unable to verify(See Commants/Explanation) <br /> 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, ❑Yes ® No ® 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. <br /> ❑Observed liquid level below operating depth <br /> Sewage tank(s)leak below their ❑Yes ® No C[Examined empty(pumped)tanks(s) <br /> designed operating depth. <br /> If yes,which sewage tank(s)leaks: El Probed outside tank(s)for"black soil" <br /> Any "yes"answer above indicates the ❑ Unable to verify(See Comments/Explanation) <br /> system is failing to protect groundwater. [I Other methods not listed(See CommentslExp/anatlon <br /> Comments/Explanation: <br /> Pumped-See attached <br /> 3. Other Compliance Conditions—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to be structurally unsound. ❑Yes* ®No ❑Unk iown <br /> b. Other issues(electrical hazards,etc.)to immediately and adversely impact public health or safety. ❑Yes* ®No ❑Unk iown <br /> *System is an imminent threat to public health and safety. <br /> Explain: <br /> c. System is non-protective of groundwater for other conditions as determined by inspector. ❑Yes* ®No <br /> *System is failing to protect groundwaW <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 f Drmats <br /> wq-wwists4-31b - 614114 Pose 2of3 <br />