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Nov 12 2015 09:25PM HP FaxRusty Olson 7634988290 page 10 <br /> Property address: 3085 Watertown Road,Orono, MN Inspector initials/Date: J.0.10/25/15 <br /> 1. Impact on Public Health—Compliance component#1 of 5 <br /> Compliance criteria: _ Verification method(s): <br /> System discharge sewage to the ❑Yes ®No ® Searched for surface outlet <br /> ground surface. ® Searched for seeping in yard/backup in home <br /> System discharge sewage to drain tile ! ❑Yes ®No ❑ Excessive ponding in soil system/D-boxes <br /> or surface waters. I ❑ Homeowner testimony(See CommentslExplanation) <br /> I--] "Black soil"above soil dispersal system <br /> System cause sewage backup into ❑Yes ®No ❑ <br /> dwelling or establishment. System requires"emergency"pumping <br /> Performed dye lest <br /> Any"yes"answer above Indicates the system Is ❑ <br /> ❑ Unable to verify(See Comments/Explanation) <br /> an Imminent Threat to Public Health and Safety. ❑ Other methods not listed(See Comments/Explanation) <br /> Co m ments/Expl a nation: <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,drywall,or leaching pit. <br /> ❑ Examined construction records <br /> Seepage pits meeting 7080.2550 may be i ❑ Examined Tank Integrity Form(Attach) <br /> _compliant if eNowed in We/ordinance. <br /> ❑ Observed liquid level below operating depth <br /> Sewage tank(s)leak below their Yes ®No <br /> designed operating depth. [3 Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s)leaks: I <br /> F-1Probedoutside tank(s)for"black sal" <br /> E3 Unable to verify(See Comments/Explanation) <br /> Any `fines"answer above Indicates the <br /> system is Failing to Protect Groundwater. ®Other methods not listed(See Comments/Explanation) <br /> Comments/Explanation: <br /> 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(e/ecbfcal 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 nonprotective of ground water for other conditions as determined by inspector ❑Yes* ®No <br /> 'System is faffing to protect groundwater <br /> Explain: <br /> www.pca.state.mn.us " 651-296.6300 • 800-657-3864 TTY 651.282.5332 or800-657-3864 . Available in alternative formats <br /> wq-ww1sts4-31 • 1124112 <br /> Page 2of3 <br />