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01/22/2015 13:35 9528733112 PAGE 02/04 <br /> c <br /> Property address: 4765 Watertown Road-Orono Inspector initials/Date: JS 1 1/22/2015 <br /> (mm/ddlAW) <br /> 1. Impact on Public Health—Compliance component#1 of 5 <br /> Com (lance criteria: Verification method(s): _ <br /> System discharges sewage to the ❑Yes 0 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 /> file or surface waters. <br /> ❑Homeowner testimony(see Commenta/explanation) <br /> System causes sewage backup into ❑Yes 0 No ❑*Black soil"above soil dispersal system <br /> dwelling or establishment. <br /> ❑System requires"emergency"pumping <br /> Any"yes"answer above indicates the ❑ Performed dye test <br /> system is an imminent threat to public ❑Unable to verity(See Commen <br /> health and satiety. te/Explanation) <br /> [�Other methods not listed (See CommenWExplanation) <br /> CommentsCplanation: <br /> 2. Tank Int ri —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,drywall,or leaching pit. ®Examined construction records <br /> Seepage pits mewing 7080,2550 may be ❑Examined Tank Integrity Form (Airach) <br /> aom lam llallowaed in local ort:lirtance, <br /> Sewage tank(s)leak below their []Yes ® No El Observed liquid level below operating depth <br /> designed operating depth. ® Examined empty(pumped)tanks(#) <br /> If yes,which sewage tank(s)leaks: ❑ Probed outside tank(s)for"black soil" <br /> Any "Y099"answer above indicates the ❑ Unable to verify(See Comments/Explanation) <br /> system is failing to protect groundwater. ❑Other methods not listed(See CommentwFkplanation) <br /> CommentMplanettlon: <br /> Cleaned tanks 502012 <br /> Septic tanks due for pumping again 5/9/2015 <br /> 3. Other Compliance Conditions—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to bs stncturally unsound. ©Yes* ®No ❑Unknown <br /> b. Other issues(e**ftr ha=rds,eta)to immediately and adversely Impact public health or safety. ❑Yes• ®No ❑Unknown <br /> *8y8MM is an iarnihient threat to pubffc health and solely, <br /> Explain- <br /> c. System is non-prob motive of ground water for other conditions as determined by inspector. ❑Yes* ®No <br /> *Sysdern Is ftffing to protect groundwmer. <br /> Explain: <br /> www.pca.state.mn.us • 651.296.6300 • 800.657.3864 TTY 651-282-5332 or NG-657-3864 • Available in attemattve formats <br /> wq-ww4sts4.3 t • 3116112 Page 2 of 3 <br />