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Property address: 106 Old Costal Bay Road N., Orono, MN Inspector initials/Date: J.O.6/20/18 <br /> 1. Impact on Public Health —Compliance component#1 of 5 <br /> Compliance criteria: Verification method(s): <br /> �— ® Searched for surface outlet <br /> System discharge sewage to the F1 Yes ® No <br /> round 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. ElHomeowner testimony(See Comments/Explanation) <br /> ❑ "Black soil"above soil dispersal system <br /> System cause sewage backup into ❑Yes ® No <br /> El System requires"emergency"pumping <br /> dwelling or establishment. <br /> —_ __ �_ ____. ❑ Performed dye test <br /> Any"yes"answer above indicates the system is ❑ Unable to verify(See CommentslExplanation) <br /> an Imminent Threat to Public 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 <br /> [I Probed tank(s)bottom <br /> ❑ <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-N allowed in local ordinance. <br /> - ❑ Observed liquid level below operating depth <br /> Sewage tank(s)leak below their [:]Yes ®No <br /> El Examined empty(pumped)tanks(s) <br /> El designed operating depth__ _____� <br /> Probed outside tank(s)for"black soil" <br /> If yes,which sewage tank(s) leaks: <br /> "—_- - --- _..___ ❑ Unable to verify(See Comments/Explanation) <br /> Any "yes"answer above indicates the ®Other methods not listed (See CommentslExplanation) <br /> system is Failing to Protect Groundwater. <br /> Com ments/Explanation: <br /> The tanks where pumped on 7/09/17.they are operating at normal level. <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(electrical 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 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 alternative formats <br /> wq-wwists4-31 • 1124112 Page 2 of 3 <br />