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Property address: 3330 Watertown Rd Orono,MN Inspector initials/Date: I <br /> (mm/dd/YM) <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. <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 verify(See CommentslExplanation) <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. ®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 ❑Examined empty(pumped)tanks(s) <br /> designed operating depth. <br /> If yes,which sewage tank(s)leaks: [:1 Probed outside tank(s)for"black soil" <br /> Any"yes"answer above indicates the El Unable to verity(Sae Comments/Explanation) <br /> system is failing to protect groundwater. El Other methods not listed(See Comments/Explanation) <br /> Com ments/Explanation: <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 ❑Unknown <br /> b. Other issues(alecbical 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 falling 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 alternative formats <br /> wq-wwists4-31b • 614114 Page 2 of 3 <br />