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Property address: 140 South Brown Rd, Orono Inspector initials/Date: JS 11.0/22/2019 <br /> (mm/dd/yyyy) <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 /> ground 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. <br /> ❑ 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 El Performed dye test <br /> system is an imminent threat to public ❑ Unable to verify(See Comments/Explanation) <br /> health and safety. <br /> ❑ 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 ❑ Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit. <br /> ® Examined construction records <br /> Seepage pits meeting 7080.2550 maybe <br /> compliant if allowed in local ordinance. ❑ Examined Tank Integrity Form (Attach) <br /> Sewage tank(s)leak below their ❑ Yes ® No ❑ Observed liquid level below operating depth <br /> designed operating depth. ® Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s) leaks. ❑ Probed outside tank(s)for"black soil" <br /> Any "yes"answer above indicates the ❑ Unable to verify(See Comments/Explanation) <br /> system is failing to protect groundwater. ❑ Other methods not listed (See Comments/Explanation) <br /> Comments/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(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 • 3/16/12 Page 2 of 3 <br />