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Property address: 1510 Green Trees Road, Orono, MN Inspector initials/Date: J. 0. 12/06119 <br />1. Impact on Public Health —Compliance component #1 of 5 <br />Compliance criteria: <br />System discharge sewage to the ❑ Yes [D No <br />ground surface. <br />System discharge sewage to drain tile ❑ Yes [D No <br />or surface waters. <br />System cause sewage backup into ❑ Yes ® No <br />dwelling or establishment. <br />Any "yes" answer above indicates the system is <br />an Imminent Threat to Public Health and Safety. <br />Comments/Explanation: <br />2. Tank Integrity —Compliance component #2 of 5 <br />Compliance criteria: <br />System consists of a seepage pit, ❑ Yes 0 No <br />cesspool, drywell, or leaching pit. <br />Seepage pits meeting 7080.2550 may be <br />compliant if allowed in local ordinance. <br />Sewage tank(s) leak below their ❑ Yes 0 No <br />designed operating depth. <br />If yes, which sewage tank(s) leaks: <br />Any "yes" answer above indicates the <br />system is Failing to Protect Groundwater. <br />Comments/Explanation: <br />Elmer J Peterson pumped the tanks on 9/26119 <br />Verification method(s): <br />® Searched for surface outlet <br />® Searched for seeping in yard/backup in home <br />❑ Excessive ponding in soil system/D-boxes <br />❑ Homeowner testimony (See CommentslExplanation) <br />❑ "Black soil" above soil dispersal system <br />❑ System requires "emergency" pumping <br />❑ Performed dye test <br />❑ Unable to verify (See CommentslExplanation) <br />❑ other methods not listed (See CommentslExplanation) <br />Verification method(s): <br />❑ Probed tank(s) bottom <br />❑ Examined construction records <br />❑ Examined Tank Integrity Form (Attach) <br />❑ Observed liquid level below operating depth <br />❑ Examined empty (pumped) tanks(s) <br />❑ Probed outside tank(s) for "black soil" <br />❑ Unable to verify (See Comments/Explanation) <br />® Other methods not listed (See CommentslExplanation) <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* Z No ❑ Unknown <br />b. Other issues (electrical hazards, etc.) to immediately and adversely impact public health or safety. ❑ Yes* E 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* M 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 />