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08/06/2015 2:44PM FAX fM0002/0004 <br /> Property address: 2165 Watertown Road,Orono Inspector initials/Date; JS 1 8/5/2015 _ <br /> (mmlddlyyyy) <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 /> ground surface. ®Searched for seeping In yard/backup in home <br /> System discharges sewage to drain ❑Yes ® No ❑ Excessive ponding in soil system/Q-boxes <br /> file or surface waters. ❑ Homeowner testimony(Sae CommentslExplanotlon) <br /> System causes sewage backup into ❑Yes ® No ❑"Black soil"above soil dispersal system <br /> dwelling or establishment. <br /> -. - ❑System requires"emergency"pumping <br /> Any"yes"answer above lndl mtes the ❑ Performed dye test <br /> system is an imminent threat to public ❑ Unable to verify(See commentwExplanatlon) <br /> health and safety. ❑Other methods not listed(See CommenWExplanation) <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. <br /> ® Examined construction records <br /> Seepage pits meeting 7080.2550 may be ❑ Examined Tank Integrity Form(Attach) <br /> compliant if allowed in focal ordinance. <br /> Sewage tank(s)leak below their El Yes ®No 0 Observed liquid level below operating depth <br /> designed operating depth. ® Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s)leaks: ❑ Probed outside tank(*)for"black soil" <br /> Any"yes"answer above indicates the ❑ Unable to verify(See CommentsoExplanation) <br /> system is failing to protect groundwater. ❑Other methods not listed(See Comments✓Explanetion) <br /> Commer ts/Explanation: <br /> pumped 2/26/2015 <br /> 3. Other Compliance Conditions—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,sacked,unsecured,or appear to be structurally unsound. ❑Yes'` ®No ❑Unknown <br /> b. Other issues(eWfical 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 groundwater for other conditions as determined by inspector. ❑Yes* ®No <br /> "System is failing to protect groundwater. <br /> Explain: <br /> www.pca.state.mn.us • 651-296-6300 • 800.657.3864 TTY 651-282-5332 or 800-657-3864 • Available in altemative formats <br /> wq-wwfsts4-31 . 3116112 Page 2 of 3 <br />