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Property address: 2140 Carrige Lane, Orono Inspector initials/Date: JS j 6/15/2018 • (mm/dd/YYYY) 1. Impact on Public Health -Compliance component#1 of 5 Compliance criteria: Verification method(s): System discharges sewage to the ❑ Yes ® No ® Searched for surface outlet ground surface. ® Searched for seeping in yard/backup in home System discharges sewage to drain ❑Yes ® No ❑ Excessive ponding in soil system/D-boxes the or surface waters. — -- ❑ Homeowner testimony(See Comments/Explanation) System causes sewage backup into ❑ Yes ® No ❑ "Black soil"above soil dispersal system dwelling or establishment. ❑ System requires"emergency„ pumping Any"yes"answer above indicates the ❑ Performed dye test system is an imminent threat to public ❑ Unable to verify(See Comments/Explanation) health and safety. ❑ Other methods not listed (See Comments/Explanation) Comments/Explanation: 2. Tank Integrity— Compliance component#2 of 5 Compliance criteria: _ Verification method(s): System consists of a seepage pit, ❑ Yes ❑ No ❑ Probed tank(s) bottom cesspool,drywell, or leaching pit. ® Examined construction records Seepage pits meeting 7080.2550 may be ❑ Examined Tank Integrity Form (Attach) compliant if allowed in local ordinance. Sewage tank(s) leak below their ❑Yes ❑ No ❑ Observed liquid level below operating depth designed operating depth. ® Examined empty(pumped)tanks(s) If yes,which sewage tank(s) leaks: 0 Probed outside tank(s)for"black soil" Any "yes"answer above indicates the ❑ Unable to verify(See Comments/Explanation) system is failing to protect groundwater. ❑ Other methods not listed(See Comments/Explanation) Comments/Explanation: 3. Other Compliance Conditions-Compliance component#3 of 5 a. Maintenance hole covers are damaged,cracked, unsecured,or appear to be structurally unsound. ❑Yes* ®No ❑Unknown b. Other issues(electrical hazards,etc.)to immediately and adversely impact public health or safety. ❑Yes* ®No ❑ Unknown *System is an imminent threat to public health and safety. Explain: c. System is non-protective of ground water for other conditions as determined by inspector. ❑Yes* ®No *System is failing to protect groundwater. Explain: www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats wq-wwists4-31 • 3/16/12 Page 2 of 3