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i <br /> Property address: 4765 Watertown Road-Orono Inspector initials/Date: JS 11/22/2015 <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 I ID Yes ®No ®Searched for surface outlet <br /> ground surface. Z 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. 0 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 Comments/Explanation) <br /> health and Safety. <br /> 0 Other methods not listed (See Comments/Explanation) <br /> Comments/Explanation: <br /> 2. Tank Integrity—Compliance component#2 of 5 <br /> Com•liance 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 may be 0 Examined Tank Integrity Form(Attach) <br /> corn.iant if allowed in local ordinance. <br /> Sewage tank(s)leak below their 1:1 Yes 0 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 El Unable to verify(See Comments/Explanation) <br /> system is failing to protect groundwater. ❑ Other methods not listed (See Comments/Explanation) <br /> Comments/Explanation: <br /> Cleaned tanks 5/9/2012 <br /> Septic tanks due for pumping again 5/9/2015 <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. 0 Yes' ®No 0 Unknown <br /> b. Other issues(electrical hazards,etc.)to immediately and adversely impact public health or safety. ❑yes* ®No 0 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. 0 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 - 3116112 Page 2 of 3 <br />